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Haines E, Shelton RC, Foley K, Beidas RS, Dressler EV, Kittel CA, Chaiyachati KH, Fayanju OM, Birken SA, Blumenthal D, Rendle KA. Addressing social needs in oncology care: another research-to-practice gap. JNCI Cancer Spectr 2024:pkae032. [PMID: 38676669 DOI: 10.1093/jncics/pkae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024] Open
Abstract
Social determinants of health and unmet social needs are directly related to cancer outcomes, from diagnosis to survivorship. If identified, unmet social needs can be addressed in oncology care by changing care plans in collaboration with patients' preferences and accounting for clinical practice guidelines (eg, reducing the frequency of appointments, switching treatment modalities) and connecting patients to resources within healthcare organizations (eg, social work support, patient navigation), and with community organizations (eg, food banks, housing assistance programs). Screening for social needs is the first step to identifying those who need additional support and is increasingly recognized as a necessary component of high-quality cancer care delivery. Despite evidence about the relationship between social needs and cancer outcomes and the abundance of screening tools, the implementation of social needs screening remains a challenge and little is known regarding the adoption, reach, and sustainability of social needs screening in routine clinical practice. We present data on the adoption and implementation of social needs screening at two large academic cancer centers and discuss three challenges associated with implementing evidence-based social needs screening in clinical practice: (1) identifying an optimal approach for administering social needs screening in oncology care, (2) adequately addressing identified unmet needs with resources and support, and (3) coordinating social needs screening between oncology and primary care.
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Affiliation(s)
- Emily Haines
- Department of Implementation Science, Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, 27101, NC
| | - Rachel C Shelton
- Mailman School of Public Health, Department of Sociomedical Sciences, Columbia University, New York, 10032, NY
| | - Kristie Foley
- Department of Implementation Science, Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, 27101, NC
| | - Rinad S Beidas
- Northwestern University Feinberg School of Medicine, 625 Michigan Avenue, Chicago, 60661, IL
| | - Emily V Dressler
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, 27101, NC
| | - Carol A Kittel
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, 27101, NC
| | - Krisda H Chaiyachati
- Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, 19104, PA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, 3400 Spruce Street, Silverstein 4, Philadelphia, 19104, PA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, 27101, NC
| | - Daniel Blumenthal
- Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, 19104, PA
| | - Katharine A Rendle
- Perelman School of Medicine, Department of Family Medicine & Community Health, University of Pennsylvania, Philadelphia, 19104, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, 19104, PA
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Falk DS, Tooze JA, Winkfield KM, Bell RA, Birken SA, Morris BB, Strom C, Copus E, Shore K, Weaver KE. Factors Associated with Delaying and Forgoing Care Due to Cost among Long-term, Appalachian Cancer Survivors in Rural North Carolina. Cancer Surviv Res Care 2023; 1:2270401. [PMID: 38178811 PMCID: PMC10766413 DOI: 10.1080/28352610.2023.2270401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/09/2023] [Indexed: 01/06/2024]
Abstract
Background Little research exists on delayed and forgone health and mental health care due to cost among rural cancer survivors. Methods We surveyed survivors in 7 primarily rural, Appalachian counties February to May 2020. Univariable analyses examined the distribution and prevalence of delayed/forgone care due to cost in the past year by independent variables. Chi-square or Fisher's tests examined bivariable differences. Logistic regressions assessed the odds of delayed/forgone care due to cost. Results Respondents (n=428), aged 68.6 years on average (SD: 12.0), were 96.3% non-Hispanic white and 49.8% female; 25.0% reported delayed/forgone care due to cost. The response rate was 18.5%. The proportion of delayed/forgone care for those aged 18-64 years was 46.7% and 15.0% for those aged 65+ years (P<0.0001). Females aged 65+ years (OR: 2.00; CI: 1.02-3.93) had double the odds of delayed/forgone care due to cost compared to males aged 65+ years. Conclusion About one in four rural cancer survivors reported delayed/forgone care due to cost, with rates approaching 50% in survivors aged <65 years. Impact Clinical implications indicate the need to: 1) ask about the impact of care costs, and 2) provide supportive services to mitigate effects of treatment costs, particularly for younger and female survivors.
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Affiliation(s)
- Derek S Falk
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157 (Sponsor)
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, Ohio, USA 44106 (Present)
| | - Janet A Tooze
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
| | - Karen M Winkfield
- Meharry-Vanderbilt Alliance, 1005 Dr. DB Todd Jr. Blvd, Nashville, TN, USA 37208
- Department of Radiation Oncology, Vanderbilt University Medical Center, Preston Research Building, Rm B-1003, 2220 Pierce Ave, Nashville, TN, USA 37232
| | - Ronny A Bell
- Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA 27599
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA 27599
| | - Sarah A Birken
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
- Department of Implementation Science, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
| | - Bonny B Morris
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157 (Sponsor)
| | - Carla Strom
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
| | - Emily Copus
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
| | - Kelsey Shore
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
| | - Kathryn E Weaver
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157 (Sponsor)
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
- Department of Implementation Science, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA 27157
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Griesemer I, Gottfredson NC, Thatcher K, Rini C, Birken SA, Kothari A, John R, Guerrab F, Clodfelter T, Lightfoot AF. Intervening in the Cancer Care System: An Analysis of Equity-Focused Nurse Navigation and Patient-Reported Outcomes. Health Promot Pract 2023:15248399231213042. [PMID: 38050901 DOI: 10.1177/15248399231213042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Nurse navigation can improve quality of cancer care and reduce racial disparities in care outcomes. Addressing persistent structurally-rooted disparities requires research on strategies that support patients by prompting structural changes to systems of care. We applied a novel conceptualization of social support to an analysis of racial equity-focused navigation and patient-reported outcomes. METHOD We applied an antiracism lens to create a theory-informed definition of system-facing social support: intervening in a care system on a patient's behalf. Participants were adults with early-stage breast or lung cancer, who racially identified as Black or White, and received specialized nurse navigation (n = 155). We coded navigators' clinical notes (n = 3,251) to identify instances of system-facing support. We then estimated models to examine system-facing support in relation to race, perceived racism in health care settings, and mental health. RESULTS Twelve percent of navigators' clinical notes documented system-facing support. Black participants received more system-facing support than White participants, on average (b = 0.78, 95% confidence interval [CI]: [0.25, 1.31]). The interaction of race*system-facing support was significant in a model predicting perceived racism in health care settings at the end of the study controlling for baseline scores (b = 0.05, 95% CI [0.01, 0.09]). Trends in simple slopes indicated that among Black participants, more system-facing support was associated with slightly more perceived racism; no association among White participants. DISCUSSION The term system-facing support highlights navigators' role in advocating for patients within the care system. More research is needed to validate the construct system-facing support and examine its utility in interventions to advance health care equity.
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Affiliation(s)
- Ida Griesemer
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
| | | | - Kari Thatcher
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
| | | | - Sarah A Birken
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Aneri Kothari
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Fatima Guerrab
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
- People's Action Institute, Washington, DC, USA
| | | | - Alexandra F Lightfoot
- Greensboro Health Disparities Collaborative, Greensboro, NC, USA
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Wheeler SB, Lee RJ, Young AL, Dodd A, Ellis C, Weiner BJ, Ribisl KM, Adsul P, Birken SA, Fernández ME, Hannon PA, Hébert JR, Ko LK, Seaman A, Vu T, Brandt HM, Williams RS. The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice. Cancer Causes Control 2023; 34:217-239. [PMID: 37354320 PMCID: PMC10689533 DOI: 10.1007/s10552-023-01691-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/29/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members. METHODS We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation. RESULTS Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change. CONCLUSION CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.
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Affiliation(s)
- Stephanie B Wheeler
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC, 27599-7411, USA.
| | - Rebecca J Lee
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexa L Young
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam Dodd
- Impact Measurement and Visualization Team, Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charlotte Ellis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC, 27599-7411, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Kurt M Ribisl
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Prajakta Adsul
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
- Cancer Control and Population Sciences Research Program, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - María E Fernández
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peggy A Hannon
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - James R Hébert
- Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- Department of Nutrition, Connecting Health Innovations LLC, Columbia, SC, USA
| | - Linda K Ko
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Aaron Seaman
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Thuy Vu
- Health Promotion Research Center, Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Heather M Brandt
- HPV Cancer Prevention Program, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Rebecca S Williams
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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5
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O'Leary MC, Hassmiller Lich K, Mayorga ME, Hicklin K, Davis MM, Brenner AT, Reuland DS, Birken SA, Wheeler SB. Engaging stakeholders in the use of an interactive simulation tool to support decision-making about the implementation of colorectal cancer screening interventions. Cancer Causes Control 2023; 34:135-148. [PMID: 37147411 PMCID: PMC10689514 DOI: 10.1007/s10552-023-01692-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/29/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE We aimed to understand how an interactive, web-based simulation tool can be optimized to support decision-making about the implementation of evidence-based interventions (EBIs) for improving colorectal cancer (CRC) screening. METHODS Interviews were conducted with decision-makers, including health administrators, advocates, and researchers, with a strong foundation in CRC prevention. Following a demonstration of the microsimulation modeling tool, participants reflected on the tool's potential impact for informing the selection and implementation of strategies for improving CRC screening and outcomes. The interviews assessed participants' preferences regarding the tool's design and content, comprehension of the model results, and recommendations for improving the tool. RESULTS Seventeen decision-makers completed interviews. Themes regarding the tool's utility included building a case for EBI implementation, selecting EBIs to adopt, setting implementation goals, and understanding the evidence base. Reported barriers to guiding EBI implementation included the tool being too research-focused, contextual differences between the simulated and local contexts, and lack of specificity regarding the design of simulated EBIs. Recommendations to address these challenges included making the data more actionable, allowing users to enter their own model inputs, and providing a how-to guide for implementing the simulated EBIs. CONCLUSION Diverse decision-makers found the simulation tool to be most useful for supporting early implementation phases, especially deciding which EBI(s) to implement. To increase the tool's utility, providing detailed guidance on how to implement the selected EBIs, and the extent to which users can expect similar CRC screening gains in their contexts, should be prioritized.
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Affiliation(s)
- Meghan C O'Leary
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria E Mayorga
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, USA
| | - Karen Hicklin
- Department of Industrial and Systems Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University, Portland State University, Portland, OR, USA
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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O'Leary MC, Hassmiller Lich K, Reuland DS, Brenner AT, Moore AA, Ratner S, Birken SA, Wheeler SB. Optimizing process flow diagrams to guide implementation of a colorectal cancer screening intervention in new settings. Cancer Causes Control 2023; 34:89-98. [PMID: 37731072 PMCID: PMC10689519 DOI: 10.1007/s10552-023-01769-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/26/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE The goal of this study was to assess acceptability of using process flow diagrams (or process maps) depicting a previously implemented evidence-based intervention (EBI) to inform the implementation of similar interventions in new settings. METHODS We developed three different versions of process maps, each visualizing the implementation of the same multicomponent colorectal cancer (CRC) screening EBI in community health centers but including varying levels of detail about how it was implemented. Interviews with community health professionals and practitioners at other sites not affiliated with this intervention were conducted. We assessed their preferences related to the map designs, their potential utility for guiding EBI implementation, and the feasibility of implementing a similar intervention in their local setting given the information available in the process maps. RESULTS Eleven community health representatives were interviewed. Participants were able to understand how the intervention was implemented and engage in discussions around the feasibility of implementing this type of complex intervention in their local system. Potential uses of the maps for supporting implementation included staff training, role delineation, monitoring and quality control, and adapting the components and implementation activities of the existing intervention. CONCLUSION Process maps can potentially support decision-making about the adoption, implementation, and adaptation of existing EBIs in new contexts. Given the complexities involved in deciding whether and how to implement EBIs, these diagrams serve as visual, easily understood tools to inform potential future adopters of the EBI about the activities, resources, and staffing needed for implementation.
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Affiliation(s)
- Meghan C O'Leary
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alison T Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexis A Moore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shana Ratner
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Petermann VM, Biddell CB, Planey AM, Spees LP, Rosenstein DL, Manning M, Gellin M, Padilla N, Samuel-Ryals CA, Birken SA, Reeder-Hayes K, Deal AM, Cabarrus K, Bell RA, Strom C, Young TH, King S, Leutner B, Vestal D, Wheeler SB. Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics. Front Health Serv 2023; 3:1148887. [PMID: 37941608 PMCID: PMC10627810 DOI: 10.3389/frhs.2023.1148887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 09/25/2023] [Indexed: 11/10/2023]
Abstract
Background Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations. Methods We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality. Results Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources. Conclusions Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.
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Affiliation(s)
- Victoria M. Petermann
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B. Biddell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Arrianna Marie Planey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa P. Spees
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Donald L. Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michelle Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Neda Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cleo A. Samuel-Ryals
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A. Birken
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Allison M. Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kendrel Cabarrus
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ronny A. Bell
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Carla Strom
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Tiffany H. Young
- Buddy Kemp Support Center, Novant Health Cancer Institute, Charlotte, NC, United States
| | - Sherry King
- Carteret Health Care Cancer Center, Carteret, NC, United States
| | - Brian Leutner
- Pardee UNC Health Care, Hendersonville, NC, United States
| | - Derek Vestal
- UNC Lenoir Health Care, Kinston, NC, United States
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Birken SA, Matulewicz R, Pathak R, Wagi CR, Peluso AG, Bundy R, Witek L, Krol B, Parchman ML, Nielsen M, Dharod A. Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use. Urol Pract 2023; 10:511-519. [PMID: 37499130 PMCID: PMC10609652 DOI: 10.1097/upj.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/16/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Citing high costs, limited diagnostic benefit, and ionizing radiation-associated risk from CT urogram, in 2020 the AUA revised its guidelines from recommending CT urogram for all patients with microscopic hematuria to a deintensified risk-stratified approach, including the deimplementation of low-value CT urogram (ie, not recommending CT urogram for patients with low- to intermediate-risk microscopic hematuria). Adherence to revised guidelines and reasons for continued low-value CT urogram are unknown. METHODS With the overarching objective of improving guideline implementation, we used a mixed-method convergent explanatory design with electronic health record data for a retrospective cohort at a single academic tertiary medical center in the southeastern United States and semistructured interviews with urology and nonurology providers to describe determinants of low-value CT urogram following guideline revision. RESULTS Of 391 patients with microscopic hematuria, 198 (51%) had a low-value CT urogram (136 [69%] pre-guideline revision, 62 [31%] postrevision). The odds of ordering a low-value CT urogram were lower after guideline revisions, but the change was not statistically significant (OR: 0.44, P = .08); odds were 1.89 higher (P = .06) among nonurology providers than urology providers, but the difference was not statistically significant. Provider interviews suggested low-value CT urogram related to nonurology providers' limited awareness of revised guidelines, the role of clinical judgment in microscopic hematuria evaluation, and professional and patient influences. CONCLUSIONS Our findings suggest low-value CT urogram deimplementation may be improved with guidelines and implementation support directed at both urology and nonurology providers and algorithms to support guideline-concordant microscopic hematuria evaluation approaches. Future studies should test these strategies.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Richard Matulewicz
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ram Pathak
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alexandra G. Peluso
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Richa Bundy
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lauren Witek
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Bridget Krol
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Matthew Nielsen
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ajay Dharod
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Wake Forest University School of Medicine, Department of Internal Medicine (IM), Section on General Internal Medicine (GIM), Winston-Salem, North Carolina
- Wake Forest Center for Healthcare Innovation (CHI), Winston-Salem, North Carolina
- Wake Forest Center for Biomedical Informatics (WFBMI), Winston-Salem, North Carolina
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9
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Birken SA, Wagi CR, Peluso AG, Kegler MC, Baloh J, Adsul P, Fernandez ME, Masud M, Huang TTK, Lee M, Wangen M, Nilsen P, Bender M, Choy-Brown M, Ryan G, Randazzo A, Ko LK. Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework. Front Health Serv 2023; 3:1142598. [PMID: 37720844 PMCID: PMC10501605 DOI: 10.3389/frhs.2023.1142598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023]
Abstract
Introduction Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. Methods The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. Results Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). Discussion Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Alexandra G. Peluso
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Michelle C. Kegler
- Emory Prevention Research Center, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jure Baloh
- College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Prajakta Adsul
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, United States
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, United States
| | - Maria E. Fernandez
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
| | - Manal Masud
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Terry T-K Huang
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
| | - Matthew Lee
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Mary Wangen
- UNC Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Miriam Bender
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, United States
| | - Mimi Choy-Brown
- College of Education and Human Development, School of Social Work, University of Minnesota, St. Paul, MN, United States
| | - Grace Ryan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Aliza Randazzo
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Linda K. Ko
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
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Ellis SD, Brooks JV, Birken SA, Morrow E, Hilbig ZS, Wulff-Burchfield E, Kinney AY, Ellerbeck EF. Determinants of targeted cancer therapy use in community oncology practice: a qualitative study using the Theoretical Domains Framework and Rummler-Brache process mapping. Implement Sci Commun 2023; 4:66. [PMID: 37308981 PMCID: PMC10259814 DOI: 10.1186/s43058-023-00441-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/25/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Precision medicine holds enormous potential to improve outcomes for cancer patients, offering improved rates of cancer control and quality of life. Not all patients who could benefit from targeted cancer therapy receive it, and some who may not benefit do receive targeted therapy. We sought to comprehensively identify determinants of targeted therapy use among community oncology programs, where most cancer patients receive their care. METHODS Guided by the Theoretical Domains Framework, we conducted semi-structured interviews with 24 community cancer care providers and mapped targeted therapy delivery across 11 cancer care delivery teams using a Rummler-Brache diagram. Transcripts were coded to the framework using template analysis, and inductive coding was used to identify key behaviors. Coding was revised until a consensus was reached. RESULTS Intention to deliver precision medicine was high across all participants interviewed, who also reported untenable knowledge demands. We identified distinctly different teams, processes, and determinants for (1) genomic test ordering and (2) delivery of targeted therapies. A key determinant of molecular testing was role alignment. The dominant expectation for oncologists to order and interpret genomic tests is at odds with their role as treatment decision-makers' and pathologists' typical role to stage tumors. Programs in which pathologists considered genomic test ordering as part of their staging responsibilities reported high and timely testing rates. Determinants of treatment delivery were contingent on resources and ability to offset delivery costs, which low- volume programs could not do. Rural programs faced additional treatment delivery challenges. CONCLUSIONS We identified novel determinants of targeted therapy delivery that potentially could be addressed through role re-alignment. Standardized, pathology-initiated genomic testing may prove fruitful in ensuring patients eligible for targeted therapy are identified, even if the care they need cannot be delivered at small and rural sites which may have distinct challenges in treatment delivery. Incorporating behavior specification and Rummler-Brache process mapping with determinant analysis may extend its usefulness beyond the identification of the need for contextual adaptation.
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Affiliation(s)
- Shellie D. Ellis
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | - Joanna Veazey Brooks
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | - Sarah A. Birken
- Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, NC 27101 USA
| | - Emily Morrow
- Kansas City Kansas Community College, 7250 State Ave., Kansas City, KS 66112 USA
| | - Zachary S. Hilbig
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | | | - Anita Y. Kinney
- Rutgers Cancer Institute of New Jersey, Rutgers University, 195 Little Albany St., New Brunswick, NJ 08901 USA
| | - Edward F. Ellerbeck
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
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Griesemer I, Birken SA, Rini C, Maman S, John R, Thatcher K, Dixon C, Yongue C, Baker S, Bosire C, Garikipati A, Ryals CA, Lightfoot AF. Mechanisms to enhance racial equity in health care: Developing a model to facilitate translation of the ACCURE intervention. SSM Qual Res Health 2023; 3:100204. [PMID: 37483653 PMCID: PMC10361418 DOI: 10.1016/j.ssmqr.2022.100204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Background As medical and public health professional organizations call on researchers and policy makers to address structural racism in health care, guidance on evidence-based interventions to enhance health care equity is needed. The most promising organizational change interventions to reduce racial health disparities use multilevel approaches and are tailored to specific settings. This study examines the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, which changed systems of care at two U.S. cancer centers and eliminated the Black-White racial disparity in treatment completion among patients with early-stage breast and lung cancer. Purpose We aimed to document key characteristics of ACCURE to facilitate translation of the intervention in other care settings. Methods We conducted semi-structured interviews with participants who were involved in the design and implementation of ACCURE and analyzed their responses to identify the intervention's mechanisms of change and key components. Results Study participants (n = 18) described transparency and accountability as mechanisms of change that were operationalized through ACCURE's key components. Intervention components were designed to enhance either institutional transparency (e.g., a data system that facilitated real-time reporting of quality metrics disaggregated by patient race) or accountability of the care system to community values and patient needs for minimally biased, tailored communication and support (e.g., nurse navigators with training in antiracism and proactive care protocols). Conclusions The antiracism principles transparency and accountability may be effective change mechanisms in equity-focused health services interventions. The model presented in this study can guide future research aiming to adapt ACCURE and evaluate the intervention's implementation and effectiveness in new settings and patient populations.
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Affiliation(s)
- Ida Griesemer
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, 150 South Huntington Avenue (152M), Jamaica Plain Campus, Building 9, Boston, MA, 02130, USA
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
| | - Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, 300 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Christine Rini
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL, 60611, USA
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Randall John
- Department of Health Policy and Management, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Kari Thatcher
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
| | - Crystal Dixon
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
- Department of Health and Exercise Science, Wake Forest University, 1834 Wake Forest Rd., Winston-Salem, NC, 27109, USA
| | - Christina Yongue
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
- Department of Public Health Education, University of North Carolina, 1408 Walker Ave # 437, Greensboro, NC, 27412, USA
| | - Stephanie Baker
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
- Department of Public Health Studies, Elon University, 100 Campus Drive, Elon, NC, 27244, USA
| | - Claire Bosire
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
| | - Aditi Garikipati
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
| | - Cleo A. Ryals
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
- Department of Health Policy and Management, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, 450 West Dr, Chapel Hill, NC, 27599, USA
- Flatiron Health, 233 Spring St., New York, NY, 10013, USA
| | - Alexandra F. Lightfoot
- Greensboro Health Disparities Collaborative, 301 S. Elm Street, Suite 414, Greensboro, NC, 27401, USA
- Department of Health Behavior, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina, 1700 MLK Jr Blvd Ste 7426, Chapel Hill, NC, 27599, USA
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12
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Shalowitz DI, Schroeder MC, Birken SA. An implementation science approach to the systematic study of access to gynecologic cancer care. Gynecol Oncol 2023; 172:78-81. [PMID: 36972637 DOI: 10.1016/j.ygyno.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Barriers to access to cancer care are profoundly threatening to patients with gynecologic malignancies. Implementation science focuses on empirical investigation of factors influencing delivery of clinical best practices, as well as interventions designed to improve delivery of evidence-based care. We outline one prominent framework for conducting implementation research and discuss its application to improving access to gynecologic cancer care. METHODS Literature on the use of the Consolidated Framework for Implementation Research (CFIR) was reviewed. Delivery of cytoreductive surgery for advanced ovarian carcinoma was selected as an illustrative case of an evidence-based intervention (EBI) in gynecologic oncology. CFIR domains were applied to the context of cytoreductive surgical care, highlighting examples of empirically-assessable determinants of care delivery. RESULTS CFIR domains include Innovation, Inner Setting, Outer Setting, Individuals, and Implementation Process. "Innovation" relates to characteristics of the surgical intervention itself; "Inner Setting" relates to the environment in which surgery is delivered. "Outer Setting" refers to the broader care environment influencing the Inner Setting. "Individuals" highlights attributes of persons directly involved in care delivery, and "Implementation Process" focuses on integration of the Innovation within the Inner Setting. CONCLUSIONS Prioritization of implementation science methods in the study of access to gynecologic cancer care will help ensure that patients are able to utilize interventions with the greatest prospect of benefiting them.
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Affiliation(s)
- David I Shalowitz
- West Michigan Cancer Center, Kalamazoo, MI, United States of America; Collaborative on Equity in Rural Cancer Care, Kalamazoo, MI, United States of America.
| | - Mary C Schroeder
- Collaborative on Equity in Rural Cancer Care, Kalamazoo, MI, United States of America; Division of Health Services Research, College of Pharmacy, University of Iowa, Iowa City, IA, United States of America
| | - Sarah A Birken
- Collaborative on Equity in Rural Cancer Care, Kalamazoo, MI, United States of America; Department of Implementation Science, School of Medicine, Wake Forest University, Winston-Salem, USA
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13
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Hwang S, Birken SA, Nielsen ME, Elston-Lafata J, Wheeler SB, Spees LP. Understanding the multilevel determinants of clinicians' imaging decision-making: setting the stage for de-implementation of low-value imaging. BMC Health Serv Res 2022; 22:1232. [PMID: 36199082 PMCID: PMC9535949 DOI: 10.1186/s12913-022-08600-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND De-implementation requires understanding and targeting multilevel determinants of low-value care. The objective of this study was to identify multilevel determinants of imaging for prostate cancer (PCa) and asymptomatic microhematuria (AMH), two common urologic conditions that have contributed substantially to the annual spending on unnecessary imaging in the US. METHODS We used a convergent mixed-methods approach involving survey and interview data. Using a survey, we asked 33 clinicians (55% response-rate) to indicate their imaging approach to 8 clinical vignettes designed to elicit responses that would demonstrate guideline-concordant/discordant imaging practices for patients with PCa or AMH. A subset of survey respondents (N = 7) participated in semi-structured interviews guided by a combination of two frameworks that offered a comprehensive understanding of multilevel determinants. We analyzed the interviews using a directed content analysis approach and identified subthemes to better understand the differences and similarities in the imaging determinants across two clinical conditions. RESULTS Survey results showed that the majority of clinicians chose guideline-concordant imaging behaviors for PCa; guideline-concordant imaging intentions were more varied for AMH. Interview results informed what influenced imaging decisions and provided additional context to the varying intentions for AMH. Five subthemes touching on multiple levels were identified from the interviews: National Guidelines, Supporting Evidence and Information Exchange, Organization of the Imaging Pathways, Patients' Clinical and Other Risk Factors, and Clinicians' Beliefs and Experiences Regarding Imaging. Imaging decisions for both PCa and AMH were often driven by national guidelines from major professional societies. However, when clinicians felt guidelines were inadequate, they reported that their decision-making was influenced by their knowledge of recent scientific evidence, past clinical experiences, and the anticipated benefits of imaging (or not imaging) to both the patient and the clinician. In particular, clinicians referred to patients' anxiety and uncertainty or patients' clinical factors. For AMH patients, clinicians additionally expressed concerns regarding legal liability risk. CONCLUSION Our study identified comprehensive multilevel determinants of imaging to inform development of de-implementation interventions to reduce low-value imaging, which we found useful for identifying determinants of de-implementation. De-implementation interventions should be tailored to address the contextual determinants that are specific to each clinical condition.
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Affiliation(s)
- Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 27599-7411, Chapel Hill, NC, USA.
| | - Sarah A Birken
- Department of Implementation Science, School of Medicine, Wake Forest University, Winston-Salem, USA
| | - Matthew E Nielsen
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 27599-7411, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA.,Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA.,Department of Urology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Jennifer Elston-Lafata
- UNC Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA.,UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 27599-7411, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 27599-7411, Chapel Hill, NC, USA.,UNC Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA
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14
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Wheeler SB, Biddell CB, Manning ML, Gellin MS, Padilla NR, Spees LP, Rogers CD, Rodriguez-O'Donnell J, Samuel-Ryals C, Birken SA, Reeder-Hayes KE, Petermann VM, Deal AM, Rosenstein DL. Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings. Trials 2022; 23:839. [PMID: 36192802 PMCID: PMC9527389 DOI: 10.1186/s13063-022-06745-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Almost half of the patients with cancer report cancer-related financial hardship, termed "financial toxicity" (FT), which affects health-related quality of life, care retention, and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes. METHODS The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21-974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients' progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness. DISCUSSION This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings. TRIAL REGISTRATION ClinicalTrials.gov NCT04931251. Registered on June 18, 2021.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Caitlin B Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mindy S Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Neda R Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cynthia D Rogers
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julia Rodriguez-O'Donnell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cleo Samuel-Ryals
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah A Birken
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Victoria M Petermann
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Birken SA, Wheeler SB, Wagi C, Manning ML, Strom C, Bell RA, Gellin M, Padilla N, Rogers C, Rodriguez-O'Donnell J, Rosenstein DL. Adaptation of a financial toxicity intervention for scale-up to diverse contexts: Core functions of Lessening the Impact of Financial Toxicity (LIFT). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
345 Background: Rural and non-English speaking populations experience a disproportionate burden of financial toxicity and access to services for their cancer care. Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, clarifies costs, and develops strategies to cope with costs. LIFT was successful in reducing financial toxicity in preliminary studies among English-speaking patients with high levels of FT in a single large academic cancer center. To benefit diverse patients with FT in cancer programs across the US, there is a need to adapt LIFT. Adapting LIFT requires distinguishing between its core functions— the components of LIFT key to its effectiveness and implementation, and its forms— the activities that comprise LIFT, facilitate its implementation, and may be adapted to accommodate new populations and contexts. We completed the first stage of adaptation, identifying LIFT core functions. Methods: We conducted interviews with individuals responsible for LIFT’s design and implementation. Interview questions were based on Kirk’s methods for identifying core functions and were recorded and transcribed verbatim. Using a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts and identified themes related to how LIFT engaged cancer program staff in FN (implementation core functions) and decreased FT (intervention core functions). Results: Eight interview participants filled various roles in designing and implementing LIFT (e.g., P.I.s; FNs). LIFT intervention core functions include a systematic way of cataloging knowledge, resources, and tracking patient information; using patient-specific needs to guide access to resources; ongoing, dynamic assistance and strong one-on-one relationships between navigators and patients; and removing common barriers to accessing resources. Conclusions: We identified core functions key to LIFT’s effectiveness and implementation. Next steps include identifying systematic differences between LIFT’s original context and population and new ones. Successfully adapting LIFT has the potential to extend its benefits to diverse patients in cancer programs throughout the US, such as Spanish-speaking patients served by rural community cancer programs.
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Affiliation(s)
| | | | | | | | - Carla Strom
- Wake Forest Baptist Health Comprehensive Cancer Center, Winston-Salem, NC
| | - Ronny A. Bell
- Wake Forest Baptist Health Comprehensive Cancer Center, Winston-Salem, NC
| | - Mindy Gellin
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Neda Padilla
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cindy Rogers
- University of North Carolina at Chapel Hill, Chapel Hill, NC
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Asad SS, Brewster WR, Kent EE, Choi Y, Spees L, Birken SA. Multi-level determinants of endometrial cancer diagnosis as experienced by Black women. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
107 Background: Black women experience inequity in access to timely endometrial cancer (EC) diagnosis compared to non-Hispanic white women. Delays in obtaining a timely diagnosis and referral for treatment can amplify poorer outcomes in Black women. Communication between Black patients and providers are likely influenced by determinants at multiple levels (e.g., individual, community, systems). Examining determinants at multiple levels can provide insight on how they influence guideline-concordant EC diagnosis in Black women through patient-provider communication. This study reports on Black women’s EC diagnosis experience, from the time of symptom onset to obtaining a diagnosis. Methods: We conducted a qualitative study using semi-structured interviews guided by the socio-cultural framework for the study of health service disparities (SCF-HSD). We used deductive thematic analysis using codes from the SCF-HSD framework, and inductive thematic analysis for new themes arising in the data. Participants were recruited using a study posting on an online patient research platform associated with an academic hospital in North Carolina. Eligible patients had to identify as Black, English-speaking, aged 40 years or older, and have a diagnosis of EC within the last 3 years. Results: Thirteen Black women with EC participated in online & phone interviews ranging from 22-50 minutes. Participants were primarily between 40-49 years of age (mean age = 45), stage II (100%), and either had private (47%), Medicare (23%) or Medicaid (30%) health insurance. Participants identified determinants at 3 levels: individual (symptom misinformation; delay in seeking support for symptoms - competing needs with work and family; fear and anxiety while waiting for tests and results), community (convenience of primary care clinics; existing relationships with providers; delay in referral by primary care providers; lack of information on testing rationale and expectations), and environment (distance to cancer centers; difficulty in obtaining appointments). Many participants reported that the onus was on them to find a cancer center and oncologist to conduct further diagnostic testing after seeing a primary care provider for their symptoms. When asked whether participants felt they were treated differently (positively/negatively) because of their race, many participants mentioned being Black negatively affected their ability to obtain timely appointments for diagnostic testing (e.g. biopsy, vaginal ultrasound). A few participants specifically mentioned reaching out to Black providers for management of their cancer. Conclusions: Black women with EC report several determinants to timely diagnosis at multiple levels. These findings will be mapped onto implementation strategies in a system-strengthening intervention to improve guideline-concordant diagnosis.
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Affiliation(s)
- Sarah S Asad
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Erin E. Kent
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Youngjee Choi
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Birken SA, Peluso A, Wagi C, Bundy R, Witek L, Krol BC, Pathak R, Nielsen ME, Matulewicz R, Parchman ML, Dharod A. Determinants of low-value imaging for patients with low-to-intermediate risk microscopic hematuria. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
27 Background: In the US, two million people are referred to urologists for the evaluation of microscopic hematuria (MH). MH guidelines were revised in 2020 by the American Urological Association, recommending that only patients at high risk for malignancy based on age, smoking history, or urinalysis receive computed tomography (CT) imaging. We found in previous studies that providers continued to use CT for patients with low-to-intermediate risk, representing low-value care. To understand reasons for continued CT use for patients with low-to-intermediate risk MH, we assessed determinants of low-value care in a concurrent mixed-method study. Methods: We stratified patients with a urology consultation within 180 days of a urinalysis documented in one academic medical center’s electronic health record between 1/1/15 and 7/1/21 into high-, intermediate-, and low-risk categories and validated risk designation in a chart review of a 5% subsample. We defined low-value care as CT for patients with low-to-intermediate-risk MH. To assess determinants of low-value MH care, we conducted semi-structured interviews with primary, urology, and gynecology providers (n = 7) identified through our professional networks. Results: Six hundred nineteen patients were referred to urology for MH. 58.6% were high-risk, 33.6% intermediate-risk, 4.4% low-risk, and 3.4% were undefined. 15.9% of intermediate-risk (n = 33) and 11.1% of low-risk (n = 3) patients received CT. Of the 14 patients referred to urology post-guideline change, none with low-to-intermediate-risk received CT. Interviews demonstrated substantial variation in approaches to MH evaluation. Urologists were largely aware of the revised guideline but noted inappropriate evaluation before referral, unnecessary referrals, and inefficiency in evaluation following referral. Lacking accessible data for risk stratification, other providers’ approaches were varied but driven by a common goal of ruling out renal malignancy, based on medical school training and institutional norms. Conclusions: Low-value care was limited but persistent and may be driven by a lack of resources to support risk-stratified MH evaluation, including accessible risk stratification data and clear guidelines for appropriate evaluation. This is consistent with a lack of practical guidance for implementing MH evaluation guidelines. In future studies, we will develop strategies to facilitate risk-stratified MH evaluation in practice.
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Affiliation(s)
| | | | | | - Richa Bundy
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Lauren Witek
- Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | | | | | | | - Ajay Dharod
- Wake Forest School of Medicine, Winston-Salem, NC
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Birken SA, Peluso A, Wagi C, Shalowitz DI, Isom S, Bell RA, Strom C, Dharod A, Bundy R, Weaver KE. Continued outpatient oncology care for cancer survivors by antineoplastic medication use: Identifying opportunities for stratified survivorship care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
226 Background: Cancer survivors may be more likely to receive preventive care services when they see both oncologists and PCPs; however, some oncology visits may not be necessary, straining limited subspecialty resources. In this study, we quantified outpatient primary and oncology care utilization in the years surrounding cancer diagnosis. We further characterized the proportion of survivors with oncology visits in the absence of ongoing antineoplastic use, as we hypothesized these survivors might be appropriate for need- and risk-stratified survivorship care, a model successful outside the US. Methods: We conducted a retrospective review of the electronic health records of survivors in an academic health center diagnosed with breast, colorectal, or uterine cancer between 1/1/14 and 9/1/19. We excluded survivors who died during the study period, had a PCP outside of our health system, or had recurrent cancers. Descriptive statistics described survivors’ provider visits up to 4 years before and 8 years after diagnosis with their most recent cancer. We then stratified our results by current antineoplastic prescription. Results: Our sample included 1,929 survivors (75.0% white, 20.1% Black, 5.0% other; 86.2% female; cancer type: 59.4% breast, 26.7% colorectal, 13.8% uterine). In the first-year post-diagnosis, 94.6% of survivors had an oncology provider visit; the figure declined to 55.8% by year 8. The percentage of survivors with PCP visits increased from 41% 3-4 years pre-diagnosis to 66% in year 1 and remained at > 50% 8 years post-diagnosis. More than 50% of survivors saw both PCPs and oncologists through 5 years post-diagnosis. Survivors were slightly more likely to have an oncology visit if they were on antineoplastics; 5+ years after diagnosis, >50% of survivors not on antineoplastics had oncology visits. Conclusions: A slight majority of 5+ year survivors, regardless of antineoplastic use, continue to have oncology visits and may be candidates for discontinuing oncology care. Work is needed to develop and test interventions to facilitate need- and risk-stratified survivorship care focused on transitioning longer-term survivors not on antineoplastics to PCPs.
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Affiliation(s)
| | | | | | | | - Scott Isom
- Comprehensive Cancer Center Wake Forest University, Winston-Salem, NC
| | - Ronny A. Bell
- Wake Forest Baptist Health Comprehensive Cancer Center, Winston-Salem, NC
| | - Carla Strom
- Wake Forest Baptist Health Comprehensive Cancer Center, Winston-Salem, NC
| | - Ajay Dharod
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Richa Bundy
- Wake Forest School of Medicine, Winston-Salem, NC
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Ellis SD, Thompson JA, Boyd SS, Roberts AW, Charlton M, Brooks JV, Birken SA, Wulff-Burchfield E, Amponsah J, Petersen S, Kinney AY, Ellerbeck E. Geographic differences in community oncology provider and practice location characteristics in the central United States. J Rural Health 2022; 38:865-875. [PMID: 35384064 PMCID: PMC9589478 DOI: 10.1111/jrh.12663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE How care delivery influences urban-rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions. METHODS We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal-Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists. FINDINGS We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural-only, urban-only, and urban-rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists. CONCLUSIONS We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation-isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban-rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization.
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Affiliation(s)
- Shellie D Ellis
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
- University of Kansas Cancer Center, Kansas City, Kansas, USA
| | - Jeffrey A Thompson
- University of Kansas Cancer Center, Kansas City, Kansas, USA
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Samuel S Boyd
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew W Roberts
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
- University of Kansas Cancer Center, Kansas City, Kansas, USA
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Joanna Veazey Brooks
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
- University of Kansas Cancer Center, Kansas City, Kansas, USA
| | - Sarah A Birken
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Elizabeth Wulff-Burchfield
- University of Kansas Cancer Center, Kansas City, Kansas, USA
- Division of Medical Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jonah Amponsah
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shariska Petersen
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Anita Y Kinney
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Haven, Kansas, USA
| | - Edward Ellerbeck
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
- University of Kansas Cancer Center, Kansas City, Kansas, USA
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Biddell CB, Spees LP, Petermann V, Rosenstein DL, Manning M, Gellin M, Padilla N, Samuel-Ryals CA, Birken SA, Reeder-Hayes K, Deal AM, Cabarrus K, Bell RA, Strom C, DeAntonio PA, Young TH, King S, Leutner B, Vestal D, Wheeler SB. Financial Assistance Processes and Mechanisms in Rural and Nonrural Oncology Care Settings. JCO Oncol Pract 2022; 18:e1392-e1406. [PMID: 35549521 PMCID: PMC9509146 DOI: 10.1200/op.21.00894] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with cancer are at heightened risk of experiencing financial hardship. Financial navigation (FN) is an evidence-based approach for identifying and addressing patient and caregiver financial needs. In preparation for the implementation of a multisite FN intervention, we describe existing processes (ie, events and actions) and mechanisms (ie, how events work together) connecting patients to financial assistance, comparing rural and nonrural practices. METHODS We conducted in-depth, semistructured interviews with stakeholders (ie, administrators, providers, and staff) at each of the 10 oncology care sites across a single state (five rural and five nonrural practices). We developed process maps for each site and analyzed stakeholder perspectives using thematic analysis. After reporting findings back to stakeholders, we synthesized themes and process maps across rural and nonrural sites separately. RESULTS Eighty-three stakeholders were interviewed. We identified six core elements of existing financial assistance processes across all sites: distress screening (including financial concerns), referrals, resource connection points, and pharmaceutical, insurance, and community/foundation resources. Processes differed by rurality; however, facilitators and barriers to identifying and addressing patient financial needs were consistent. Open communication between staff, providers, patients, and caregivers was a primary facilitator. Barriers included insufficient staff resources, challenges in routinely identifying needs, inadequate preparation of patients for anticipated medical costs, and limited tracking of resource availability and eligibility. CONCLUSION This study identified a clear need for systematic implementation of oncology FN to equitably address patient and caregiver financial hardship. Results have informed our current efforts to implement a multisite FN intervention, which involves comprehensive financial toxicity screening and systematization of intake and referrals.
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Affiliation(s)
- Caitlin B. Biddell
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Lisa P. Spees
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Victoria Petermann
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC
| | - Donald L. Rosenstein
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Michelle Manning
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Mindy Gellin
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Neda Padilla
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Cleo A. Samuel-Ryals
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Sarah A. Birken
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Katherine Reeder-Hayes
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Division of Oncology, Chapel Hill, NC
| | - Allison M. Deal
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Kendrel Cabarrus
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
| | - Ronny A. Bell
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Carla Strom
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Tiffany H. Young
- Novant Health Cancer Institute, Buddy Kemp Support Center, Charlotte, NC
| | - Sherry King
- Carteret Health Care Cancer Center, Morehead City, NC
| | | | | | - Stephanie B. Wheeler
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Birken SA, Ko LK, Wangen M, Wagi CR, Bender M, Nilsen P, Choy-Brown M, Peluso A, Leeman J. Increasing Access to Organization Theories for Implementation Science. Front Health Serv 2022; 2:891507. [PMID: 36925845 PMCID: PMC10012830 DOI: 10.3389/frhs.2022.891507] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022]
Abstract
Background Organization theories offer numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying evidence-based intervention (EBI) implementation. Rooted in ideas regarding power, autonomy, and control, organization theories can explain how and why organizations adopt, implement, and sustain EBI use. Although they have gained visibility, organization theories remain underused in implementation research, perhaps due to their inaccessibility to implementation scientists. To improve access to organization theory among implementation scientists, we summarized organization theories with relevance to implementation science. Methods Led by the Cancer Prevention and Control Research Network (CPCRN) Organization Theory for Implementation Science workgroup, we employed a modified Delphi process to reach a consensus among 18 experts at the intersection of organization and implementation science regarding organization theories with relevance to implementation science. From texts that described the organization theories, using standardized abstraction forms, two investigators independently abstracted information regarding constructs, propositions regarding how or why constructs might influence implementation, the potential relevance of organization theories' propositions for implementation, and overviews of each theory. The investigators then reconciled discrepancies until reaching consensus. A third investigator reviewed reconciled abstraction forms for accuracy, coherence, and completeness. Findings We identified nine organization theories with relevance to implementation science: contingency, complexity, institutional, network, organizational learning, resource dependence, sociotechnical, and transaction cost economics. From the theories, we abstracted 70 constructs and 65 propositions. An example proposition from institutional theory is: "Coercive, mimetic, and normative pressures contribute to organizations…within an organizational field [becoming increasingly similar]." These propositions can be operationalized as levers to facilitate EBI implementation. Conclusions To increase use in the field, organization theories must be made more accessible to implementation scientists. The abstraction forms developed in this study are now publicly available on the CPCRN website with the goal of increasing access to organization theories among an interdisciplinary audience of implementation scientists through the CPCRN Scholars program and other venues. Next steps include consolidating organization theory constructs into domains and translating the resulting framework for use among researchers, policymakers and practitioners, aiding them in accounting for a comprehensive set of organization theory constructs thought to influence EBI implementation.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Linda K. Ko
- Washington School of Public Health, Health Systems and Population Health, Seattle, WA, United States
| | - Mary Wangen
- UNC Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Miriam Bender
- Sue & Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mimi Choy-Brown
- School of Social Work, College of Education and Human Development, University of Minnesota, St. Paul, MN, United States
| | - Alexandra Peluso
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jennifer Leeman
- School of Nursing, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
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Birken SA, Haines ER. Organization theory for implementation science. Implement Sci 2022. [DOI: 10.4324/9781003109945-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Wahlen MM, Schroeder MC, Johnson EC, Lizarraga IM, Engelbart JM, Tatman DJ, Wagi C, Charlton ME, Birken SA. Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals. Front Health Serv 2022; 2. [PMID: 36188431 PMCID: PMC9524475 DOI: 10.3389/frhs.2022.891574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background: Rural patients experience worse cancer survival outcomes than urban patients despite similar incidence rates, due in part to significant barriers to accessing quality cancer care. Community hospitals in non-metropolitan/rural areas play a crucial role in providing care to patients who desire and are able to receive care locally. However, rural community hospitals typically face challenges to providing comprehensive care due to lack of resources. The University of Kentucky’s Markey Cancer Center Affiliate Network (MCCAN) is an effective complex, multi-level intervention, improving cancer care in rural/under-resourced hospitals by supporting them in achieving American College of Surgeons Commission on Cancer (CoC) standards. With the long-term goal of adapting MCCAN for other rural contexts, we aimed to identify MCCAN’s core functions (i.e., the components key to the intervention’s effectiveness/implementation) using theory-driven qualitative data research methods. Methods: We conducted eight semi-structured virtual interviews with administrators, coordinators, clinicians, and certified tumor registrars from five MCCAN affiliate hospitals that were not CoC-accredited prior to joining MCCAN. Study team members coded interview transcripts and identified themes related to how MCCAN engaged affiliate sites in improving care quality (intervention functions) and implementing CoC standards (implementation functions) and analyzed themes to identify core functions. We then mapped core functions onto existing theories of change and presented the functions to MCCAN leadership to confirm validity and completeness of the functions. Results: Intervention core functions included: providing expertise and templates for achieving accreditation, establishing a culture of quality-improvement among affiliates, and fostering a shared goal of quality care. Implementation core functions included: fostering a sense of community and partnership, building trust between affiliates and Markey, providing information and resources to increase feasibility and acceptability of meeting CoC standards, and mentoring and empowering administrators and clinicians to champion implementation. Conclusion: The MCCAN intervention presents a more equitable strategy of extending the resources and expertise of large cancer centers to assist smaller community hospitals in achieving evidence-based standards for cancer care. Using rigorous qualitative methods, we distilled this intervention into its core functions, positioning us (and others) to adapt the MCCAN intervention to address cancer disparities in other rural contexts.
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Affiliation(s)
- Madison M. Wahlen
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Mary C. Schroeder
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, IA, United States
- *Correspondence: Mary C. Schroeder
| | - Erin C. Johnson
- Department of Management and Entrepreneurship, University of Iowa, Iowa City, IA, United States
| | - Ingrid M. Lizarraga
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Jacklyn M. Engelbart
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - David J. Tatman
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Cheyenne Wagi
- Department of Implementation Science, Wake Forest University, Winston-Salem, NC, United States
| | - Mary E. Charlton
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Sarah A. Birken
- Department of Implementation Science, Wake Forest University, Winston-Salem, NC, United States
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Alishahi Tabriz A, Turner K, Clary A, Hong YR, Nguyen OT, Wei G, Carlson RB, Birken SA. De-implementing low-value care in cancer care delivery: a systematic review. Implement Sci 2022; 17:24. [PMID: 35279182 PMCID: PMC8917720 DOI: 10.1186/s13012-022-01197-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 02/14/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings. METHODS We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care. RESULTS Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias. CONCLUSIONS This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).
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Affiliation(s)
- Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Alecia Clary
- The Reagan-Udall Foundation for the FDA, 1900 L Street, NW, Suite 835, Washington, DC, 20036 USA
| | - Young-Rock Hong
- UF Health Cancer Center, Gainesville, FL USA
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, HPNP Building, Room 3111, Gainesville, FL 32610 USA
| | - Oliver T. Nguyen
- Department of Community Health & Family Medicine, University of Florida, P.O. Box 100211, Gainesville, FL 32610 USA
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL USA
| | - Grace Wei
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Rebecca B. Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, 335 S. Columbia Street, Chapel Hill, NC 27599 USA
| | - Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC 27157 USA
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Anderson DM, Gupta AK, Birken SA, Sakas Z, Freeman MC. Adaptation in rural water, sanitation, and hygiene programs: A qualitative study in Nepal. Int J Hyg Environ Health 2022; 240:113919. [PMID: 35033992 PMCID: PMC8821331 DOI: 10.1016/j.ijheh.2022.113919] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
Adaptations are modifications made to programming to improve effectiveness or contextual fit, and are important for program improvement. However, adaptations can be detrimental if they do not preserve an intervention's underlying theory of change. We present a case study of 45 adaptations made to rural WaSH programming in Nepal, identified through qualitative interviews with implementers conducted in June through August 2019. For each adaptation, we characterized its target outcomes and implementers' motivations for making the adaptation, and we assessed the adaptation's intended and unintended effects on program quality. Participants described adaptations to both interventions (e.g., changes to hygiene promotion messages) and implementation strategies (e.g., sanctions to enforce toilet construction, such as denying work permits to households without a toilet). Adoption was the most common target outcome, specifically increasing toilet construction. Other target outcomes included feasibility of program delivery, acceptability of messages or WaSH products, reach of program activities in the community, and sustainability. Implementers were commonly motivated by intense pressure to meet national open defecation free targets. Most adaptations achieved their target outcomes. However, sanctions adaptations had substantial unintended negative effects. Implementers reported that sanctions were unpopular with communities and had poor sustainability. In contrast, non-sanctions adaptations that targeted outcomes of feasibility, acceptability, and sustainability had few unintended negative consequences. Our findings suggest that adaptations to promote rapid adoption of toilet construction do not consistently achieve sustained behavior change. Furthermore, adaptations to improve feasibility of program delivery or cost and acceptability of WaSH products can indirectly improve adoption even when it is not an explicit target outcome.
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Affiliation(s)
- Darcy M Anderson
- The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, USA.
| | - Ankush Kumar Gupta
- Nepal Health Research Council, Ramshah Path, Kathmandu, P.O.Box 7626, Nepal
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 475 Vine Street, Winston-Salem, NC, 27101, USA; Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Zoe Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA, 30322, USA
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE, Atlanta, GA, 30322, USA
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Hwang S, Bozkurt B, Huson T, Asad S, Richardson L, Ogbansiegbe JA, Viera L, Buse C, James TA, Mayer DK, Shulman LN, Birken SA. Identifying Strategies for Robust Survivorship Program Implementation: A Qualitative Analysis of Cancer Programs. JCO Oncol Pract 2022; 18:e304-e312. [PMID: 34606296 PMCID: PMC8932497 DOI: 10.1200/op.21.00357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The Commission on Cancer seeks to promote robust survivorship programs among accredited cancer programs. In practice, cancer programs' survivorship programs range from cursory (eg, developing care plans without robust services) to robust (eg, facilitating follow-up care). To inform cancer programs' future efforts, in this study, we identified the implementation strategies that cancer programs used to achieve robust survivorship programs, distinguishing them from cursory programs. METHODS We sampled 39 cancer programs across the United States with approaches to survivorship program implementation ranging from cursory to robust on the basis of LIVESTRONG survivorship care consensus elements. Within sampled cancer programs, we conducted in-depth semistructured interviews with a total of 42 health care professionals. We used template analysis to distinguish implementation strategies used in cancer programs with robust survivorship programs from strategies that yielded cursory survivorship programs. RESULTS Cancer programs with robust survivorship programs established clear systems survivorship care and formal committees to improve the survivorship care processes. They sought buy-in from multiple stakeholders to leverage cancer program resources and defined clear roles with shared accountability among multidisciplinary groups. By contrast, cancer programs with cursory survivorship programs reported less consistency in survivorship care processes and lacked buy-in from key stakeholders. They had limited resources, faced persistent structural concerns, and had insufficient clarity in roles among team members. CONCLUSION Accrediting bodies may consider incorporating the implementation strategies that robust survivorship programs have used as guidance for supporting cancer programs in operationalizing survivorship care and evaluating the use of these strategies during the accreditation and review process.
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Affiliation(s)
- Soohyun Hwang
- Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC,Soohyun Hwang, MPH, Health Policy and Management, University of North Carolina Chapel Hill, 135 Dauer Drive, Chapel Hill, NC;
| | - Burcu Bozkurt
- Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Tamara Huson
- Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Sarah Asad
- Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Lauren Richardson
- Health Policy and Management/Kenan-Flagler Business School, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Laura Viera
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Caroline Buse
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ted A. James
- Breast Center/Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Deborah K. Mayer
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | - Sarah A. Birken
- Wake Forest University School of Medicine, Winston-Salem, NC
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Leeman J, Wangen M, Kegler M, Lee M, O'Leary MC, Ko LK, Fernández ME, Birken SA. Applying Theory to Explain the Influence of Factors External to an Organization on the Implementation of an Evidence-Based Intervention. Front Health Serv 2022; 2:889786. [PMID: 36925840 PMCID: PMC10012829 DOI: 10.3389/frhs.2022.889786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022]
Abstract
Despite its widely acknowledged influence on implementation, limited research has been done on how the external environment (i.e., outer setting) determines when organizations adopt and implement new interventions. Determinant frameworks identify several outer setting-level factors such as funding streams, inter-organizational relationships, and peer pressure. However, these frameworks do not explain how or why outer-setting factors influence implementation. To advance research in this area, we argue for the importance of deriving theory-based propositions from organization theory to explain how outer setting factors influence organizations. Drawing on the work of the Organization Theory in Implementation Science (OTIS) project, we identified 20 propositions from five classic organization theories-Complexity Theory, Contingency Theory, Institutional Theory, Resource Dependence Theory, and Transaction Cost Economics. We then applied those propositions to hypothesize relationships among outer setting factors, implementation strategies, and implementation outcomes in five case studies of evidenced-based tobacco control interventions. The five case studies address the implementation of smoke-free policies, community health worker-led tobacco education and cessation programs, 5 A's (Ask, Advise, Assess, Assist, and Arrange), point-of-sale tobacco marketing policy interventions, and quitlines. The case studies illustrate how propositions may be used to guide the selection and testing of implementation strategies. Organization theories provide a menu of propositions that offer guidance for selecting and optimizing high-leverage implementation strategies that target factors at the level of outer setting. Furthermore, these propositions suggest testable hypotheses regarding the mechanisms underlying the influence of outer-setting factors on how and why organizations adopt and implement interventions.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mary Wangen
- Center for Health Promotion / Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michelle Kegler
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health of Emory University, Atlanta, GA, United States
| | - Matthew Lee
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Meghan C O'Leary
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Linda K Ko
- Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - María E Fernández
- Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
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28
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Wheeler SB, Birken SA, Wagi CR, Manning ML, Gellin M, Padilla N, Rogers C, Rodriguez J, Biddell CB, Strom C, Bell RA, Rosenstein DL. Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings. Front Health Serv 2022; 2:958831. [PMID: 36925862 PMCID: PMC10012722 DOI: 10.3389/frhs.2022.958831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Abstract
Background Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions. Methods We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes. Results Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions. Conclusion This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.
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Affiliation(s)
- Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Cheyenne R Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Neda Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cindy Rogers
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julia Rodriguez
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B Biddell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carla Strom
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Ronny Antonio Bell
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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29
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Anderson DM, Birken SA, Bartram JK, Freeman MC. Adaptation of Water, Sanitation, and Hygiene Interventions: A Model and Scoping Review of Key Concepts and Tools. Front Health Serv 2022; 2:896234. [PMID: 36925880 PMCID: PMC10012759 DOI: 10.3389/frhs.2022.896234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022]
Abstract
Background Safe water, sanitation, and hygiene (WaSH) is important for health, livelihoods, and economic development, but WaSH programs have often underdelivered on expected health benefits. Underperformance has been attributed partly to poor ability to retain effectiveness following adaptation to facilitate WaSH programs' implementation in diverse contexts. Adaptation of WaSH interventions is common but often not done systematically, leading to poor outcomes. Models and frameworks from the adaptation literature have potential to improve WaSH adaptation to facilitate implementation and retain effectiveness. However, these models and frameworks were designed in a healthcare context, and WaSH interventions are typically implemented outside traditional health system channels. The purpose of our work was to develop an adaptation model tailored specifically to the context of WaSH interventions. Methods We conducted a scoping review to identify key adaptation steps and identify tools to support systematic adaptation. To identify relevant literature, we conducted a citation search based on three recently published reviews on adaptation. We also conducted a systematic database search for examples of WaSH adaptation. We developed a preliminary model based on steps commonly identified across models in adaptation literature, and then tailored the model to the WaSH context using studies yielded by our systematic search. We compiled a list of tools to support systematic data collection and decision-making throughout adaptation from all included studies. Results and Conclusions Our model presents adaptation steps in five phases: intervention selection, assessment, preparation, implementation, and sustainment. Phases for assessment through sustainment are depicted as iterative, reflecting that once an intervention is selected, adaptation is a continual process. Our model reflects the specific context of WaSH by including steps to engage non-health and lay implementers and to build consensus among diverse stakeholders with potentially competing priorities. We build on prior adaptation literature by compiling tools to support systematic data collection and decision-making, and we describe how they can be used throughout adaptation steps. Our model is intended to improve program outcomes by systematizing adaptation processes and provides an example of how systematic adaptation can occur for interventions with health goals but that are implemented outside conventional health system channels.
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Affiliation(s)
- Darcy M Anderson
- Public Health and Environment, The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Medical Center Boulevard, Winston-Salem, NC, United States
| | - Jamie K Bartram
- Public Health and Environment, The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,School of Civil Engineering, University of Leeds, Leeds, United Kingdom
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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30
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Matulewicz RS, Feuer Z, Birken SA, Makarov DV, Sherman SE, Bjurlin MA, El Shahawy O. National assessment of recommendations from healthcare providers for smoking cessation among adults with cancer. Cancer Epidemiol 2021; 78:102088. [PMID: 34930697 PMCID: PMC10071779 DOI: 10.1016/j.canep.2021.102088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/07/2021] [Accepted: 12/12/2021] [Indexed: 11/15/2022]
Abstract
Cancer survivors benefit from evidence-based smoking cessation treatment. A crucial first step in this process is a clinician recommending that the patient quit smoking. However, contemporary delivery of advice to quit among patients with cancer is not well known. In a cross-sectional analysis of all adult smokers included in a prospective population-representative study of US adults, we analyzed the frequency that patients reported receiving advice to quit smoking from a healthcare professional according to reported cancer history (no cancer, tobacco-related cancer, non-tobacco related cancer history). Among an estimated 28.3 million smokers, 9.3% reported a history of cancer, 48.8% of which were tobacco-related cancers. In general, advice to quit was reported by more (67.8%) cancer survivors than those adults without any cancer (56.0%). After adjustment for sociodemographic factors, smokers with a non tobacco-related cancer (0.51, 95% CI 0.32-0.83) and those without any cancer history (0.43, 95% CI 0.30-0.63) were both less likely to report being advised to quit smoking than patients with a tobacco-related cancer history.
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Affiliation(s)
- Richard S Matulewicz
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Urology Service, USA; VA New York Harbor Healthcare System, USA.
| | - Zachary Feuer
- VA New York Harbor Healthcare System, USA; New York University, Grossman School of Medicine, Department of Urology, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System, USA; New York University, Grossman School of Medicine, Department of Urology, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, USA; New York University, School of Global Public Health, Division of Global Health, USA
| | - Marc A Bjurlin
- University of North Carolina, Department of Urology, Lineberger Comprehensive Cancer Center, USA
| | - Omar El Shahawy
- New York University, School of Global Public Health, Division of Global Health, USA
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Jonas DE, Barclay C, Grammer D, Weathington C, Birken SA, DeWalt DA, Shoenbill KA, Boynton MH, Mackey M, Riley S, Cykert S. The STUN (STop UNhealthy) Alcohol Use Now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care. Trials 2021; 22:810. [PMID: 34784953 PMCID: PMC8593635 DOI: 10.1186/s13063-021-05641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unhealthy alcohol use is a leading cause of preventable deaths in the USA and is associated with many societal and health problems. Less than a third of people who visit primary care providers in the USA are asked about or ever discuss alcohol use with a health professional. METHODS/DESIGN This study is an adaptive, randomized, controlled trial to evaluate the effect of primary care practice facilitation and telehealth services on evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use in small-to-medium-sized primary care practices. Study participants will include primary care practices in North Carolina with 10 or fewer providers. All enrolled practices will receive a practice facilitation intervention that includes quality improvement (QI) coaching, electronic health record (EHR) support, training, and expert consultation. After 6 months, practices in the lower 50th percentile (based on performance) will be randomized to continued practice facilitation or provision of telehealth services plus ongoing facilitation for the next 6 months. Practices in the upper 50th percentile after the initial 6 months of intervention will continue to receive practice facilitation alone. The main outcome measures include the number (and %) of patients in the target population who are screened for unhealthy alcohol use, screen positive, and receive brief counseling. Additional measures include the number (and %) of patients who receive pharmacotherapy for AUD or are referred for AUD services. Sample size calculations determined that 35 practices are needed to detect a 10% increase in the main outcome (percent screened for unhealthy alcohol use) over 6 months. DISCUSSION A successful intervention would significantly reduce morbidity among adults from unhealthy alcohol use by increasing counseling and other treatment opportunities. The study will produce important evidence about the effect of practice facilitation on uptake of evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use when delivered on a large scale to small and medium-sized practices. It will also generate scientific knowledge about whether embedded telehealth services can improve the use of evidence-based screening and interventions for practices with slower uptake. The results of this rigorously conducted evaluation are expected to have a positive impact by accelerating the dissemination and implementation of evidence related to unhealthy alcohol use into primary care practices. TRIAL REGISTRATION ClinicalTrials.gov NCT04317989 . Registered on March 23, 2020.
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Affiliation(s)
- Daniel E Jonas
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA.
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Colleen Barclay
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Debbie Grammer
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Chris Weathington
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, 27101, USA
| | - Darren A DeWalt
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Kimberly A Shoenbill
- Department of Family Medicine, CB 7370, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Program on Health and Clinical Informatics, CB 7064, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Marcella H Boynton
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Monique Mackey
- North Carolina Area Health Education Centers, CB 7165, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sean Riley
- Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, Ohio, 43221, USA
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Samuel Cykert
- Cecil G. Sheps Center for Health Services Research, CB 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Division of General Medicine and Clinical Epidemiology, CB 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Birken SA, Peluso A, Wagi C, Wentworth S, Weaver KE. Feasibility and preliminary effectiveness of a cancer survivorship care delivery intervention. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
19 Background: A large and rapidly increasing number of US cancer survivors who have completed active treatment continue to seek oncology care. Low-risk survivors who continue to seek oncology care incur greater costs but experience worse care quality and outcomes than those who seek primary care. In this study, we assessed the feasibility and preliminary effectiveness of START (Supporting Transitions AfteR Treatment), a theory-driven, stakeholder-engaged intervention intended to improve the transition of low-risk survivors to primary care. Methods: To pilot START, beginning in August 2020, we engaged oncology providers (n = 5) and staff (n = 4) at a small community affiliate of our academic comprehensive cancer center. We worked with a nurse navigator, office manager, and physician champion to refine START’s content and delivery to accommodate the needs of a busy community cancer center. We queried electronic health records (EHRs) to assess the feasibility of identifying low-risk survivors and measuring key outcomes (i.e., receipt of recommended health maintenance services). In a formal meeting, we introduced providers to START and helped them to identify survivors whom they agreed should be transitioned to primary care. Front desk staff flagged these survivors to remind providers to transition them in upcoming appointments. Beginning in July 2021, we will conduct in-depth, semi-structured interviews with oncology providers and staff and survivors regarding their perspectives on START’s acceptability, appropriateness, and feasibility. Results: We successfully identified survivors using EHRs and engaged the nurse navigator and providers in identifying the subset of survivors whom they deemed eligible for transitioning to primary care. Preliminary results indicate that START helped providers to transition eligible survivors to primary care. We have successfully engaged cancer center data managers in measuring relevant outcomes using EHRs. Informal provider and staff feedback suggests that START is an acceptable, appropriate, and feasible approach to transitioning survivors. Conclusions: At the conference, we will report on oncology provider and staff and survivor perceptions of START’s acceptability, appropriateness, and feasibility for improving survivorship care delivery and preliminary findings regarding START’s effectiveness in increasing survivors’ receipt of recommended health maintenance services. Findings will be used to refine START and form the basis of a clinical trial to evaluate its effectiveness in improving survivorship outcomes.
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Hwang S, Birken SA. Determinants of urologists’ adherence to active surveillance follow-up protocol for low-risk prostate cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12 Background: The National Comprehensive Cancer Network (NCCN) guideline offers a guideline for follow-up care for patients with low-risk prostate cancer on active surveillance (AS). However, in practice, 70% of patients receive follow-up care that is not guideline-adherent, characterized by insufficient or excessive surveillance testing, potentially diminishing AS effectiveness and contributing to poor patient outcomes. The objective of this study is to identify provider- and organization-level determinants of guideline-adherent AS follow-up care. Methods: We used in-depth semi-structured qualitative interviews with 13 United States urologists to examine determinants of urologists’ adherence to the active surveillance follow-up guideline. Guided by the combined use of the Consolidated Framework for Implementation Research, which focuses on organization-level determinants, and the Theoretical Domains Framework, which focuses on provider-level determinants, we used template analysis to identify multilevel determinants of urologists’ adherence to guideline-recommended AS follow-up care. Results: Relevant determinants were comfort with varied utilization behaviors of the guideline, perspectives on the prostate biopsy procedure, and the degree of structure within the practice setting. At the provider level, there was variation in how urologists provided AS follow-up care. All urologists referred to the NCCN guideline; however, most urologists adapted the guidelines to their needs and/or comfort level (e.g., following a subset of recommendations; adapting the interval/frequency of serial tests). Most providers felt that strictly adhering to the repeated biopsy aspect of the guideline was difficult because of concerns about fitting everybody to one type of frequency that does not stratify patients by risk. Others reflected on patients expressing physical discomfort and concerns of infection stemming from the biopsy procedure. At the organization level, urologists in a structured practice environment had the tendency towards providing NCCN guideline-adherent care whereas urologists practicing in settings with less organization relied more on individual discretion, which created room for flexibility with the care that they provide. Conclusions: Both provider- and organization-level determinants affected urologists’ provision of NCCN guideline-adherent follow-up care which may partially explain why patients eventually fail to receive guideline-adherent AS follow-up care. Findings call on the need for multilevel strategies to increase adherence or to modify existing guidelines to reflect the need at multiple levels.
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Affiliation(s)
- Soohyun Hwang
- University of North Carolina Chapel Hill, Chapel Hill, NC
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Haines ER, Kirk MA, Lux L, Smitherman AB, Powell BJ, Dopp A, Stover AM, Birken SA. Ethnography and user-centered design to inform context-driven implementation. Transl Behav Med 2021; 12:6315391. [PMID: 34223893 DOI: 10.1093/tbm/ibab077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite pervasive findings pointing to its inextricable role in intervention implementation, context remains poorly understood in implementation science. Existing approaches for describing context (e.g., surveys, interviews) may be narrow in scope or superficial in their elicitation of contextual data. Thus, in-depth and multilevel approaches are needed to meaningfully describe the contexts into which interventions will be implemented. Moreover, many studies assess context without subsequently using contextual information to enhance implementation. To be useful for improving implementation, though, methods are needed to apply contextual information during implementation. In the case example presented in this paper, we embedded an ethnographic assessment of context within a user-centered design approach to describe implementation context and apply that information to promote implementation. We developed a patient-reported outcome measure-based clinical intervention to assess and address the pervasive unmet needs of young adults with cancer: the Needs Assessment & Service Bridge (NA-SB). In this paper, we describe the user-centered design process that we used to anticipate context modifications needed to deliver NA-SB and implementation strategies needed to facilitate its implementation. Our ethnographic contextual inquiry yielded a rich understanding of local implementation context and contextual variation across potential scale-up contexts. Other methods from user-centered design (i.e., translation tables and a design team prototyping workshop) allowed us to translate that information into specifications for NA-SB delivery and a plan for implementation. Embedding ethnographic methods within a user-centered design approach can help us to tailor interventions and implementation strategies to their contexts of use to promote implementation.
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Affiliation(s)
- Emily R Haines
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Lauren Lux
- UNC Adolescent and Young Adult Cancer Program, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Andrew B Smitherman
- Pediatric Hematology-Oncology, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Alex Dopp
- RAND Corporation, Santa Monica, CA, USA
| | - Angela M Stover
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Birken SA, Currie G. Correction to: Using organization theory to position middle-level managers as agents of evidence-based practice implementation. Implement Sci 2021; 16:43. [PMID: 33882990 PMCID: PMC8061167 DOI: 10.1186/s13012-021-01121-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, CV4 7AL, UK
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Birken SA, Currie G. Using organization theory to position middle-level managers as agents of evidence-based practice implementation. Implement Sci 2021; 16:37. [PMID: 33836781 PMCID: PMC8034157 DOI: 10.1186/s13012-021-01106-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
Middle-level managers (MLMs; i.e., healthcare professionals who may fill roles including obtaining and diffusing information, adapting information and the intervention, mediating between strategy and day-to-day activities, and selling intervention implementation) have been identified as having significant influence on evidence-based practice (EBP) implementation. We argue that understanding whether and how MLMs influence EBP implementation is aided by drawing upon organization theory. Organization theories propose strategies for increasing MLMs' opportunities to facilitate implementation by optimizing their appreciation of constructs which we argue have heretofore been treated separately to the detriment of understanding and facilitating implementation: EBPs, context, and implementation strategies. Specifically, organization theory encourages us to delineate different types of MLMs and consider how generalist and hybrid MLMs make different contributions to EBP implementation. Organization theories also suggest that MLMs' understanding of context allows them to adapt EBPs to promote implementation and effectiveness; MLMs' potential vertical linking pin role may be supported by increasing MLMs' interactions with external environment, helping them to understand strategic pressures and opportunities; and how lateral connections among MLMs have the potential to optimize their contribution to EBP implementation as a collective force. We end with recommendations for practice and future research.
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Affiliation(s)
- Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, CV4 7AL, UK
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Rogers L, De Brún A, Birken SA, Davies C, McAuliffe E. Context counts: a qualitative study exploring the interplay between context and implementation success. J Health Organ Manag 2021; ahead-of-print. [PMID: 33682395 PMCID: PMC9073593 DOI: 10.1108/jhom-07-2020-0296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice. DESIGN/METHODOLOGY/APPROACH The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success. FINDINGS Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams. ORIGINALITY/VALUE By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.
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Affiliation(s)
- Lisa Rogers
- School of Nursing, Midwifery and Health Systems, UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin, Dublin, Ireland
| | - Aoife De Brún
- School of Nursing, Midwifery and Health Systems, UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin, Dublin, Ireland
| | - Sarah A Birken
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carmel Davies
- School of Nursing, Midwifery and Health Systems, UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin, Dublin, Ireland
| | - Eilish McAuliffe
- School of Nursing, Midwifery and Health Systems, UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin, Dublin, Ireland
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Haines ER, Lux L, Smitherman AB, Kessler ML, Schonberg J, Dopp A, Stover AM, Powell BJ, Birken SA. An actionable needs assessment for adolescents and young adults with cancer: the AYA Needs Assessment & Service Bridge (NA-SB). Support Care Cancer 2021; 29:4693-4704. [PMID: 33511477 DOI: 10.1007/s00520-021-06024-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/21/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE In the USA, many of the nearly 90,000 adolescents and young adults (AYAs) diagnosed with cancer each year do not receive services to address the full scope of needs they experience during and after cancer treatment. To facilitate a systematic and patient-centered approach to delivering services to address the unmet needs of AYAs with cancer, we developed the AYA Needs Assessment & Service Bridge (NA-SB). METHODS To develop NA-SB, we leveraged user-centered design, an iterative process for intervention development based on prospective user (i.e., provider and AYA) engagement. Specifically, we conducted usability testing and concept mapping to refine an existing tool-the Cancer Needs Questionnaire-Young People-to promote its usability and usefulness in routine cancer practice. RESULTS Our user-centered design process yielded a need assessment which assesses AYAs' physical, psychosocial, and practical needs. Importantly, needs in the assessment are grouped by services expected to address them, creating an intuitive and actionable link between needs and services. CONCLUSION NA-SB has the potential to improve care coordination at the individual level by allowing cancer care programs to tailor service delivery and resource provision to the individual needs of AYAs they serve.
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Affiliation(s)
- Emily R Haines
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, 525 Vine Street, Winston-Salem, NC, 27101, USA.
| | - Lauren Lux
- UNC Adolescent and Young Adult Cancer Program, Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Andrew B Smitherman
- Pediatric Hematology-Oncology, Lineberger Comprehensive Cancer Center, 101 Manning Dr, Chapel Hill, NC, 27514, USA
| | - Melody L Kessler
- Department of Chemistry, University of North Carolina at Chapel Hill, 125 South Road, Chapel Hill, NC, 27599-3290, USA
| | - Jacob Schonberg
- Center for Excellence in Community Mental Health, Department of Psychiatry, University of North Carolina School of Medicine, 3010 Falstaff Rd, Raleigh, NC, 27610, USA
| | - Alex Dopp
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA
| | - Angela M Stover
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27516, USA
| | - Byron J Powell
- Brown School & School of Medicine, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Matulewicz RS, Makarov DV, Sherman SE, Birken SA, Bjurlin MA. Urologist-led smoking cessation: a way forward through implementation science. Transl Androl Urol 2021; 10:7-11. [PMID: 33532289 PMCID: PMC7844518 DOI: 10.21037/tau-20-1204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Richard S Matulewicz
- Department of Urology, NYU Grossman School of Medicine, New York, NY, USA.,Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.,Manhattan Campus, VA NY Harbor Health System, New York, NY, USA
| | - Danil V Makarov
- Department of Urology, NYU Grossman School of Medicine, New York, NY, USA.,Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.,Manhattan Campus, VA NY Harbor Health System, New York, NY, USA
| | - Scott E Sherman
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.,Manhattan Campus, VA NY Harbor Health System, New York, NY, USA
| | | | - Marc A Bjurlin
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.,Department of Urology, University of North Carolina, Chapel Hill, NC, USA
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Nilsen P, Potthoff S, Birken SA. Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change. Front Health Serv 2021; 1:795144. [PMID: 36926485 PMCID: PMC10012728 DOI: 10.3389/frhs.2021.795144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022]
Abstract
Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed. Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours. Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed. Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change.
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Affiliation(s)
- Per Nilsen
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sebastian Potthoff
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
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Biddell CB, Spees LP, Mayer DK, Wheeler SB, Trogdon JG, Rotter J, Birken SA. Developing personalized survivorship care pathways in the United States: Existing resources and remaining challenges. Cancer 2020; 127:997-1004. [PMID: 33259060 DOI: 10.1002/cncr.33355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.,School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Rogers L, De Brún A, Birken SA, Davies C, McAuliffe E. The micropolitics of implementation; a qualitative study exploring the impact of power, authority, and influence when implementing change in healthcare teams. BMC Health Serv Res 2020; 20:1059. [PMID: 33228702 PMCID: PMC7684932 DOI: 10.1186/s12913-020-05905-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. Methods The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A = 16, Case B = 15) and twenty-five interviews (Case A = 13, Case B = 12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). Results The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants’ experiences of the implementation process. Conclusion To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05905-z.
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Affiliation(s)
- Lisa Rogers
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland.
| | - Aoife De Brún
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, Noth Carolina, USA
| | - Carmel Davies
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
| | - Eilish McAuliffe
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), University College Dublin School of Nursing, Midwifery and Health Systems, Dublin, Ireland
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Hwang S, Bozkurt B, Huson T, Asad S, Richardson L, Ogbansiegbe J, Viera L, Buse C, Mayer D, Shulman LN, Birken SA. Strategies for comprehensive implementation of survivorship care: A qualitative analysis of CoC-accredited cancer programs. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
209 Background: The Commission on Cancer (CoC) seeks to promote comprehensive approaches to implementing survivorship programs among accredited cancer programs. In practice, cancer programs’ approaches range from cursory (e.g., developing care plans without robust services) to comprehensive (e.g., facilitating follow-up care). This study identified strategies that were unique to cancer programs with comprehensive approaches to implementing survivorship programs. Methods: We sampled 39 CoC-accredited cancer programs with approaches to survivorship program implementation ranging from cursory to comprehensive, as reported in CoC annual surveys. Within sampled cancer programs, we conducted in-depth semi-structured interviews with a total of 42 healthcare professionals (1-2/program). We identified strategies unique to cancer programs with comprehensive approaches by comparing them to cancer programs with cursory approaches. Results: Cancer programs with comprehensive approaches to implementing survivorship programs had formal committees with ample opportunities to evaluate the progress, revise roles, and acquire multiple stakeholders’ support. Keeping a good record system enabled these cancer programs to meet accreditation requirements and improve processes. Buy-in from upper management and key physicians was deemed crucial in leveraging cancer program resources. These programs also had clear roles with shared accountability among multidisciplinary groups. Like cancer programs with comprehensive approaches to implementing survivorship programs, many cancer programs with cursory approaches also had formal committees; however, cancer programs with cursory approaches lacked buy-in from key stakeholders, relying on few staff or a champion for implementation. Cancer programs with cursory approaches had limited resources, cumbersome processes, and team members with unclear roles. Conclusions: Cancer programs with comprehensive approaches to survivorship program implementation gained broad stakeholder buy-in and established clear team member roles with shared accountability. Study findings will inform more than 1500 CoC-accredited US cancer programs’ approaches to implementing survivorship programs. At the conference, we will have results from quantitative and measures validation companion studies.
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Affiliation(s)
- Soohyun Hwang
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Burcu Bozkurt
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Tamara Huson
- MACPAC: Medicaid and CHIP Payment and Access Commission, Washington, DC
| | - Sarah Asad
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | | | | | - Laura Viera
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Caroline Buse
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | | | | | - Sarah A. Birken
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Wheeler SB, Spees L, Biddell CB, Rotter J, Trogdon JG, Birken SA, Mayer D. Development of a personalized follow-up care algorithm for Medicare breast cancer survivors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
204 Background: The rapidly growing number of cancer survivors in the US have substantial healthcare needs requiring surveillance and care for the late and long-term effects of cancer treatment and comorbidities. Lacking a clear system of care, experts recommend a personalized approach to survivorship care. The objective of this study was to test a clinical prediction algorithm to distinguish low-complexity breast cancer survivors who may be suited to self-manage their survivorship care and be followed by their primary care provider (PCP) from survivors who require specialty care. Methods: We used the Surveillance and Epidemiology End Results (SEER) registry – Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to identify women diagnosed with stage 0-3 breast cancer between 2003 and 2011. Cross-validated random forest machine learning models separately estimated survivors’ independent risk of all-cause death, cancer-specific death, recurrence, or severe late effects within 3 years following treatment completion. The absence of these outcomes identified survivors as potentially eligible for self-management and PCP care. Predictors included measures of baseline health status and health care utilization, patient socio-demographic characteristics, cancer characteristics, and financial burden. Results: Among the 4,516 survivors in the primary cohort, 82% were white, and the mean (SD) age was 75.1 (7.8) years. Almost 50% were diagnosed with Stage I breast cancer, followed by 25.2% with Stage 2, 19.3% with Stage 0, and 5.6% with Stage III. Within the 3-year follow-up period, 372 (8.2%) survivors died (111 or 2.5% from cancer), 665 (14.7%) experienced recurrence, and 488 (10.8%) were hospitalized due to severe late effects. Predicting all-cause death resulted in 91.9% out-of-sample accuracy, a 37.6% improvement over an uninformed model. Important predictors across outcomes included age, geographic region, diagnosis year, financial burden, comorbidities, and cancer stage. Conclusions: Survivors requiring specialty care are characterized by higher comorbidity, lower educational attainment, and advanced age, suggesting that, in addition to cancer characteristics, personalized care pathways developed in response to our findings must account for social and contextual factors as well.
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Affiliation(s)
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Sarah A. Birken
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah Mayer
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Birken SA, Haines ER, Hwang S, Chambers DA, Bunger AC, Nilsen P. Advancing understanding and identifying strategies for sustaining evidence-based practices: a review of reviews. Implement Sci 2020; 15:88. [PMID: 33036653 PMCID: PMC7545853 DOI: 10.1186/s13012-020-01040-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation science has focused mainly on the initial uptake and use of evidence-based practices (EBPs), with less attention to sustainment-i.e., continuous use of these practices, as intended, over time in ongoing operations, often involving adaptation to dynamic contexts. Declining EBP use following implementation is well-documented yet poorly understood. Using theories, models, and frameworks (TMFs) to conceptualize sustainment could advance understanding. We consolidated knowledge from published reviews of sustainment studies to identify TMFs with the potential to conceptualize sustainment, evaluate past uses of TMFs in sustainment studies, and assess the TMFs' potential contribution to developing sustainment strategies. METHODS We drew upon reviews of sustainment studies published within the past 10 years, evaluated the frequency with which included articles used a TMF for conceptualizing sustainment, and evaluated the relevance of TMFs to sustainment research using the Theory, Model, and Framework Comparison and Selection Tool (T-CaST). Specifically, we examined whether the TMFs were familiar to researchers, hypothesized relationships among constructs, provided a face-valid explanation of relationships, and included sustainment as an outcome. FINDINGS Nine sustainment reviews referenced 648 studies; these studies cited 76 unique TMFs. Only 28 TMFs were used in more than one study. Of the 19 TMFs that met the criteria for T-CaST analysis, six TMFs explicitly included sustainment as the outcome of interest, 12 offered face-valid explanations of proposed conceptual relationships, and six identified mechanisms underlying relationships between included constructs and sustainment. Only 11 TMFs performed adequately with respect to all these criteria. CONCLUSIONS We identified 76 TMFs that have been used in sustainment studies. Of these, most were only used once, contributing to a fractured understanding of sustainment. Improved reporting and use of TMFs may improve understanding of this critical topic. Of the more consistently used TMFs, few proposed face-valid relationships between included constructs and sustainment, limiting their ability to advance our understanding and identify potential sustainment strategies. Future research is needed to explore the TMFs that we identified as potentially relevant, as well as TMFs not identified in our study that nonetheless have the potential to advance our understanding of sustainment and identification of strategies for sustaining EBP use.
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Affiliation(s)
- Sarah A. Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 1103E McGavran-Greenberg, 135 Dauer Drive, Campus Box 7411, Chapel Hill, NC 27599-7411 USA
| | - Emily R. Haines
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, 1101B McGavran - Greenberg Hall, CB# 7411, Chapel Hill, NC 27599-7411 USA
| | - Soohyun Hwang
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, 1101B McGavran - Greenberg Hall, CB# 7411, Chapel Hill, NC 27599-7411 USA
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 3E414, Rockville, MD 20850 USA
| | - Alicia C. Bunger
- College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43210 USA
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden
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Kirk MA, Moore JE, Wiltsey Stirman S, Birken SA. Towards a comprehensive model for understanding adaptations' impact: the model for adaptation design and impact (MADI). Implement Sci 2020; 15:56. [PMID: 32690104 PMCID: PMC7370455 DOI: 10.1186/s13012-020-01021-y] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background Implementation science is shifting from qualifying adaptations as good or bad towards understanding adaptations and their impact. Existing adaptation classification frameworks are largely descriptive (e.g., who made the adaptation) and geared towards researchers. They do not help practitioners in decision-making around adaptations (e.g., is an adaptation likely to have negative impacts? Should it be pursued?). Moreover, they lack constructs to consider “ripple effects” of adaptations (i.e., both intended and unintended impacts on outcomes, recognizing that an adaptation designed to have a positive impact on one outcome may have unintended impacts on other outcomes). Finally, they do not specify relationships between adaptations and outcomes, including mediating and moderating relationships. The objective of our research was to promote systematic assessment of intended and unintended impacts of adaptations by using existing frameworks to create a model that proposes relationships among constructs. Materials and methods We reviewed, consolidated, and refined constructs from two adaptation frameworks and one intervention-implementation outcome framework. Using the consolidated and refined constructs, we coded qualitative descriptions of 14 adaptations made to an existing evidence-based intervention; the 14 adaptations were designed in prior research by a stakeholder panel using a modified Delphi approach. Each of the 14 adaptations had detailed descriptions, including the nature of the adaptation, who made it, and its goal and reason. Using coded data, we arranged constructs from existing frameworks into a model, the Model for Adaptation Design and Impact (MADI), that identifies adaptation characteristics, their intended and unintended impacts (i.e., ripple effects), and potential mediators and moderators of adaptations’ impact on outcomes. We also developed a decision aid and website (MADIguide.org) to help implementation scientists apply MADI in their work. Results and conclusions Our model and associated decision aids build on existing frameworks by comprehensively characterizing adaptations, proposing how adaptations impact outcomes, and offering practical guidance for designing adaptations. MADI encourages researchers to think about potential causal pathways of adaptations (e.g., mediators and moderators) and adaptations’ intended and unintended impacts on outcomes. MADI encourages practitioners to design adaptations in a way that anticipates intended and unintended impacts and leverages best practice from research.
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Affiliation(s)
- M Alexis Kirk
- The Impact Center, Frank Porter Graham Child Development Institute, The University of North Carolina at Chapel Hill, 105 Smith Level Road, Chapel Hill, NC, 27599, USA.
| | - Julia E Moore
- The Center for Implementation, 20 Northampton Dr., Toronto, ON, M9B 4S6, Canada
| | - Shannon Wiltsey Stirman
- National Center for PTSD and Stanford University, 795 Willow Road NC-PTSD, Menlo Park, CA, 94024, USA
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest School of Medicine, 475 Vine Street, Winston-Salem, NC, 27101, USA
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Hwang S, Birken SA, Melvin CL, Rohweder CL, Smith JD. Designs and methods for implementation research: Advancing the mission of the CTSA program. J Clin Transl Sci 2020; 4:159-167. [PMID: 32695483 PMCID: PMC7348037 DOI: 10.1017/cts.2020.16] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/15/2020] [Accepted: 02/20/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The US National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in response to the challenges of translating biomedical and behavioral interventions from discovery to real-world use. To address the challenge of translating evidence-based interventions (EBIs) into practice, the field of implementation science has emerged as a distinct discipline. With the distinction between EBI effectiveness research and implementation research comes differences in study design and methodology, shifting focus from clinical outcomes to the systems that support adoption and delivery of EBIs with fidelity. METHODS Implementation research designs share many of the foundational elements and assumptions of efficacy/effectiveness research. Designs and methods that are currently applied in implementation research include experimental, quasi-experimental, observational, hybrid effectiveness-implementation, simulation modeling, and configurational comparative methods. RESULTS Examples of specific research designs and methods illustrate their use in implementation science. We propose that the CTSA program takes advantage of the momentum of the field's capacity building in three ways: 1) integrate state-of-the-science implementation methods and designs into its existing body of research; 2) position itself at the forefront of advancing the science of implementation science by collaborating with other NIH institutes that share the goal of advancing implementation science; and 3) provide adequate training in implementation science. CONCLUSIONS As implementation methodologies mature, both implementation science and the CTSA program would greatly benefit from cross-fertilizing expertise and shared infrastructures that aim to advance healthcare in the USA and around the world.
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Affiliation(s)
- Soohyun Hwang
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah A. Birken
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cathy L. Melvin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Catherine L. Rohweder
- UNC Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin D. Smith
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Nilsen P, Seing I, Ericsson C, Birken SA, Schildmeijer K. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res 2020; 20:147. [PMID: 32106847 PMCID: PMC7045403 DOI: 10.1186/s12913-020-4999-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing disease patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can be challenging because they contradict humans' basic need for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful. METHODS The study was based on semi-structured interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health care system. An inductive approach was applied using questions based on the existing literature on organizational change and change responses. The questions concerned the interviewees' experiences and perceptions of any changes that they considered to have affected their work, regardless of whether these changes were "objectively" large or small changes. The interviewees' responses were analysed using directed content analysis. RESULTS The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the need for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients. CONCLUSIONS Organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients.
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Affiliation(s)
- Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, University of Linköping, Linköping, Sweden.
| | - Ida Seing
- Department of Behavioural Sciences and Learning, University of Linköping, Linköping, Sweden
| | - Carin Ericsson
- Department of Medical and Health Sciences, Division of Community Medicine, University of Linköping, Linköping, Sweden.,Cardiology and Speciality Medicine Centre, Region Östergötland, Linköping, Sweden
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Kirk MA, Haines ER, Rokoske FS, Powell BJ, Weinberger M, Hanson LC, Birken SA. A case study of a theory-based method for identifying and reporting core functions and forms of evidence-based interventions. Transl Behav Med 2019; 11:21-33. [PMID: 31793635 DOI: 10.1093/tbm/ibz178] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Adaptation of existing evidence-based interventions (EBIs) to improve their fit in new contexts is common. A critical first step in adaptation is to identify core functions (purposes) and forms (activities) of EBIs. Core functions should not be adapted as they are what account for the efficacy of EBIs. Despite their importance, core functions are rarely identified by EBI developers; methods for identifying them post hoc are lacking. We present a case study of theory-based methods for identifying core functions and forms post hoc. We developed these methods as the first step in a larger effort to adapt an existing EBI to improve the timeliness of referrals to hospice to a new patient population and care setting. Our methods were rooted in the Planned Adaptation Model (PAM). Through our case study, we developed six steps for identifying core functions and forms, as well as accompanying tools and methods. Our case study further operationalized PAM in several ways. Where PAM offered guiding tenets for identifying core functions and forms (review existing EBI materials, conduct primary data collection, and identify the theory of change), we produced specific tools (interview guides and codebooks) and methods (sampling approaches and analytic methods). Our case study extended PAM with the addition of two steps in the process of identifying core functions and forms: (a) identifying the usual care pathway, including barriers to the outcome of interest encountered in usual care, and (b) mapping EBI core functions onto an extant theory. Identifying core functions and forms is a critical first step in the adaptation process to ensure adaptations do not inadvertently compromise the efficacy or effectiveness of the EBI by compromising core functions. Our case study presents step-by-step methods that could be used by researchers or practitioners to identify core functions and forms post hoc.
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Affiliation(s)
- M Alexis Kirk
- The Impact Center at Frank Porter Graham Child Development Institute, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Emily R Haines
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Franziska S Rokoske
- End-of-Life, Palliative, and Hospice Care Program, RTI International, Research Triangle Park, NC, USA
| | - Byron J Powell
- Brown School at Washington University in St. Louis, St. Louis, MO, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Leeman J, Baquero B, Bender M, Choy-Brown M, Ko LK, Nilsen P, Wangen M, Birken SA. Advancing the use of organization theory in implementation science. Prev Med 2019; 129S:105832. [PMID: 31521385 PMCID: PMC7076554 DOI: 10.1016/j.ypmed.2019.105832] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023]
Abstract
Healthcare settings and systems have been slow to adopt and implement many effective cancer prevention and control interventions. Understanding the factors that determine successful implementation is essential to accelerating the translation of effective interventions into practice. Many scholars have studied the determinants of implementation, and much of this research has been guided by the Consolidated Framework for Implementation Research (CFIR). The CFIR categorizes implementation determinants at five levels (characteristics of the intervention, inner setting, individual, processes, and outer setting). Of these five levels, determinants at the level of the outer setting are the least developed. Extensive research in fields other than healthcare suggest that determinants at the level of the outer setting (e.g., funding streams, contracting practices, and public policy) play a central role in shaping when and how an organization implements new structures and practices. Thus, a more comprehensive understanding of outer-setting determinants is critical to efforts to accelerate the implementation of effective cancer control interventions. The Cancer Prevention and Control Research Network (CPCRN) created a cross-center workgroup to review organizational theories and begin to contribute to the creation of a future framework of constructs related to outer setting determinants. In this paper, we report findings from the review of three organizational theories: Institutional Theory, Transaction Cost Economics, and Contingency Theory. To demonstrate the applicability of this work to implementation science and practice, we have applied findings to three case studies of CPCRN researchers' efforts to implement colorectal cancer screening interventions in Federally Qualified Health Centers.
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Affiliation(s)
- Jennifer Leeman
- University of North Carolina at Chapel Hill, School of Nursing, 4005 Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460, United States of America.
| | - Barbara Baquero
- University of Washington, School of Public Health, Box 354805, Seattle, WA 98195, United States of America.
| | - Miriam Bender
- University of California, Irvine, Sue & Bill Gross School of Nursing, 252C Berk Hall, Irvine, CA 92697-3959, United States of America.
| | - Mimi Choy-Brown
- University of Minnesota, Twin Cities, School of Social Work, Room 269 Peters Hall, 1404 Gortner Ave, Saint Paul, MN 55108, United States of America.
| | - Linda K Ko
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., M3-B232, Seattle, WA 98109-1024, United States of America; University of Washington, Department of Health Services, 1959 NE Pacific Street, Magnuson Health Sciences Bldg., Box 357660, Seattle, WA 98195, United States of America.
| | - Per Nilsen
- Linköping University, SE-581 83 Linköping, Sweden.
| | - Mary Wangen
- University of North Carolina at Chapel Hill, School of Nursing, 3005 Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460, United States of America.
| | - Sarah A Birken
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 1106F McGavran-Greenberg CB #7411, Chapel Hill, NC 27599-7411, United States of America.
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