http://www.implementationscience.com The latest research articles published by Implementation Science 2013-05-22T00:00:00Z Background: The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.Design/methods: We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma---the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis---the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.DiscussionThis study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.Trial registration: ClinicalTrials.gov: NCT01815710https://register.clinicaltrials.gov http://www.implementationscience.com/content/8/1/55 Mona Jabbour Janet Curran Shannon Scott Astrid Guttman Thomas Rotter Francine Ducharme M Lougheed M McNaughton-Filion Amanda Newton Mark Shafir Alison Paprica Terry Klassen Monica Taljaard Jeremy Grimshaw David Johnson Implementation Science 2013, null:55 2013-05-22T00:00:00Z doi:10.1186/1748-5908-8-55 /content/figures/1748-5908-8-55-toc.gif Implementation Science 1748-5908 ${item.volume} 55 2013-05-22T00:00:00Z PDF Background: Despite the considerable and growing body of knowledge translation (KT) literature, there are few methodologies sufficiently detailed to guide an integrated KT research approach for a population health study. This paper argues for a clearly articulated collaborative KT approach to be embedded within the research design from the outset.DiscussionPopulation health studies are complex in their own right, and strategies to engage the local community in adopting new interventions are often fraught with considerable challenges. In order to maximise the impact of population health research, more explicit KT strategies need to be developed from the outset. We present four propositions, arising from our work in developing a KT framework for a population health study. These cover the need for an explicit theory-informed conceptual framework; formalizing collaborative approaches within the design; making explicit the roles of both the stakeholders and the researchers; and clarifying what counts as evidence. From our deliberations on these propositions, our own co-creating (co-KT) Framework emerged in which KT is defined as both a theoretical and practical framework for actioning the intent of researchers and communities to co-create, refine, implement and evaluate the impact of new knowledge that is sensitive to the context (values, norms and tacit knowledge) where it is generated and used. The co-KT Framework has five steps. These include initial contact and framing the issue; refining and testing knowledge; interpreting, contextualising and adapting knowledge to the local context; implementing and evaluating; and finally, the embedding and translating of new knowledge into practice.SummaryAlthough descriptions of how to incorporate KT into research designs are increasing, current theoretical and operational frameworks do not generally span a holistic process from knowledge co-creation to knowledge application and implementation within one project. Population health studies may have greater health impact when KT is incorporated early and explicitly into the research design. This, we argue, will require that particular attention be paid to collaborative approaches, stakeholder identification and engagement, the nature and sources of evidence used, and the role of the research team working with the local study community. http://www.implementationscience.com/content/8/1/54 Alison Kitson Kathryn Powell Elizabeth Hoon Jonathan Newbury Anne Wilson Justin Beilby Implementation Science 2013, null:54 2013-05-21T00:00:00Z doi:10.1186/1748-5908-8-54 /content/figures/1748-5908-8-54-toc.gif Implementation Science 1748-5908 ${item.volume} 54 2013-05-21T00:00:00Z PDF Background: Prognostic models in reproductive medicine can help to identify subfertile couples who would benefit from fertility treatment. Expectant management in couples with a good chance of natural conception, i.e., tailored expectant management (TEM), prevents unnecessary treatment and is therefore recommended in international fertility guidelines. However, current implementation is not optimal, leaving room for improvement. Based on barriers and facilitators for TEM that were recently identified among professionals and subfertile couples, we have developed a multifaceted implementation strategy. The goal of this study is to assess the effects of this implementation strategy on the guideline adherence on TEM. Methods: In a cluster randomized trial, 25 clinics and their allied practitioners units will be randomized between the multifaceted implementation strategy and care as usual. Randomization will be stratified for in vitro fertilization (IVF) facilities (full licensed, intermediate/no IVF facilities). The effect of the implementation strategy, i.e., the percentage guideline adherence on TEM, will be evaluated by pre- and post-randomization data collection. Furthermore, there will be a process and cost evaluation of the strategy. The implementation strategy will focus on subfertile couples and their care providers i.e., general practitioners (GPs), fertility doctors, and gynecologists. The implementation strategy addresses three levels: patient level: education materials in the form of a patient information leaflet and a website; professional level: audit and feedback, educational outreach visit, communication training, and access to a digital version of the prognostic model of Hunault on a website; organizational level: providing a protocol based on the guideline. The primary outcome will be the percentage guideline adherence on TEM. Additional outcome measures will be treatment-, patient-, and process-related outcome measures.DiscussionThis study will provide evidence about the effectiveness and costs of a multifaceted implementation strategy to improve guideline adherence on TEM.Trial registration: www.trialregister.nl NTR3405. This study is sponsored by ZonMW. http://www.implementationscience.com/content/8/1/53 Noortje van den Boogaard Fleur Kersten Mariëtte Goddijn Patrick Bossuyt Fulco van der Veen Peter Hompes Rosella Hermens Didi Braat Ben Mol Willianne Nelen Implementation Science 2013, null:53 2013-05-20T00:00:00Z doi:10.1186/1748-5908-8-53 /content/figures/1748-5908-8-53-toc.gif Implementation Science 1748-5908 ${item.volume} 53 2013-05-20T00:00:00Z PDF Background: Influenced by an important paper by Michie et al., outlining the rationale and requirements for detailed reporting of behavior change interventions now required by Implementation Science, we created and refined a checklist to operationalize the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations in systematic reviews. The WIDER recommendations provide a framework to identify and provide detailed reporting of the essential components of behavior change interventions in order to facilitate replication, further development, and scale-up of the interventions.FindingsThe checklist was developed, applied, and improved over the course of four systematic reviews of knowledge translation (KT) strategies in a variety of healthcare settings conducted by Scott and associates. The checklist was created as one method of operationalizing the work of the WIDER in order to facilitate comparison across heterogeneous studies included in these systematic reviews. Numerous challenges were encountered in the process of creating and applying the checklist across four stages of development. The resulting improvements have produced a ‘user-friendly’ and replicable checklist to assess the quality of reporting of KT interventions in systematic reviews using the WIDER recommendations. Conclusions: With journals, such as Implementation Science, using the WIDER recommendations as publication requirements for evaluation reports of behavior change intervention studies, it is crucial to find methods of examining, measuring, and reporting the quality of reporting. This checklist is one approach to operationalize the WIDER recommendations in systematic review methodology. http://www.implementationscience.com/content/8/1/52 Lauren Albrecht Mandy Archibald Danielle Arseneau Shannon Scott Implementation Science 2013, null:52 2013-05-16T00:00:00Z doi:10.1186/1748-5908-8-52 /content/figures/1748-5908-8-52-toc.gif Implementation Science 1748-5908 ${item.volume} 52 2013-05-16T00:00:00Z XML Background: In the United States, as in many other parts of the world, the prevalence of overweight/obesity is at epidemic proportions in the adult population and even higher among Veterans. To address the high prevalence of overweight/obesity among Veterans, the MOVE!® weight management program was disseminated nationally to Veteran Affairs (VA) medical centers. The objective of this paper is two-fold: to describe factors that explain the wide variation in implementation of MOVE!; and to illustrate, step-by-step, how to apply a theory-based framework using qualitative data. Methods: Five VA facilities were selected to maximize variation in implementation effectiveness and geographic location. Twenty-four key stakeholders were interviewed about their experiences in implementing MOVE!. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of qualitative data. Constructs that most strongly influence implementation effectiveness were identified through a cross-case comparison of ratings. Results: Of the 31 CFIR constructs assessed, ten constructs strongly distinguished between facilities with low versus high program implementation effectiveness. The majority (six) were related to the inner setting: networks and communications; tension for change; relative priority; goals and feedback; learning climate; and leadership engagement. One construct each, from intervention characteristics (relative advantage) and outer setting (patient needs and resources), plus two from process (executing and reflecting) also strongly distinguished between high and low implementation. Two additional constructs weakly distinguished, 16 were mixed, three constructs had insufficient data to assess, and one was not applicable. Detailed descriptions of how each distinguishing construct manifested in study facilities and a table of recommendations is provided. Conclusions: This paper presents an approach for using the CFIR to code and rate qualitative data in a way that will facilitate comparisons across studies. An online Wiki resource (http://www.wiki.cfirwiki.net) is available, in addition to the information presented here, that contains much of the published information about the CFIR and its constructs and sub-constructs. We hope that the described approach and open access to the CFIR will generate wide use and encourage dialogue and continued refinement of both the framework and approaches for applying it. http://www.implementationscience.com/content/8/1/51 Laura Damschroder Julie Lowery Implementation Science 2013, null:51 2013-05-10T00:00:00Z doi:10.1186/1748-5908-8-51 /content/figures/1748-5908-8-51-toc.gif Implementation Science 1748-5908 ${item.volume} 51 2013-05-10T00:00:00Z XML Background: More effective methods are needed to implement evidence-based findings into practice. TheAdvancing Recovery Framework offers a multi-level approach to evidence-based practiceimplementation by aligning purchasing and regulatory policies at thepayer level withorganizational change strategies at the organizational level. Methods: The Advancing Recovery Buprenorphine Implementation Study is a cluster-randomizedcontrolled trial designed to increase use of the evidence-based practice buprenorphinemedication to treat opiate addiction. Ohio Alcohol, Drug Addiction, and Mental HealthServices Boards (ADAMHS), who are payers, and their addiction treatment organizationswere recruited for a trial to assess the effects of payerand treatment organization changes(using the Advancing Recovery Framework) versus treatment organization changes alone onthe use of buprenorphine. A matched-pair randomization, based on county characteristics,was applied, resulting in seven county ADAMHS boards and twenty-five treatmentorganizations in each arm. Opioid dependent patients are nested within cluster (treatmentorganization), and treatment organization clusters are nested withinADAMHS county board.The primary outcome is the percentage of individuals with an opioid dependence diagnosiswho use buprenorphine during the 24-month intervention period and the 12-monthsustainability period. The trial is currently in the baseline data collection stage.DiscussionAlthough addiction treatment providers are under increasing pressureto implement evidence-based practices that have been proven to improve patient outcomes, adoption ofthesepractices lags, compared to other areas of healthcare. Reasonsfrequently cited for the slowadoption of EBPs in addiction treatment include, regulatory issues, staff, or client resistanceand lack of resources. Yet the way addiction treatment is funded, thepayer's role--has notreceived a lot of attention in research on EBP adoption.This research is unique because it investigates the role of payers in evidence-based practiceimplementation using a randomized controlled design instead of case examples. The testingof the Advancing Recovery Framework is designed to broaden the understanding of theimpact payers have on evidence-based practice (EBP) adoption.Trial registrationNCT01702142 (ClinicalTrials.gov registry, USA) http://www.implementationscience.com/content/8/1/50 Todd Molfenter Jee-Seon Kim Andrew Quanbeck Terry Patel-Porter Sandy Starr Dennis McCarty Implementation Science 2013, null:50 2013-05-10T00:00:00Z doi:10.1186/1748-5908-8-50 /content/figures/1748-5908-8-50-toc.gif Implementation Science 1748-5908 ${item.volume} 50 2013-05-10T00:00:00Z PDF Background: Adaptation of high-quality practice guidelines for local use has been advanced as an efficient means to improve acceptability and applicability of evidence-informed care. In a pan-Canadian study, we examined how cancer care groups adapted pre-existing guidelines to their unique context and began implementation planning. Methods: Using a mixed-methods, case-study design, five cases were purposefully sampled from self-identified groups and followed as they used a structured method and resources for guideline adaptation. Cases received the ADAPTE Collaboration toolkit, facilitation, methodological and logistical support, resources and assistance as required. Documentary and primary data collection methods captured individual case experience, including monthly summaries of meeting and field notes, email/telephone correspondence, and project records. Site visits, process audits, interviews and a final evaluation forum with all cases contributed to a comprehensive account of participant experience. Results: Study cases took 12 to >24 months to complete guideline adaptation. Although participants appreciated the structure, most found the ADAPTE method complex and lacking practical aspects. They needed assistance establishing individual guideline mandate and infrastructure, articulating health questions, executing search strategies, appraising evidence, and achieving consensus. Facilitation was described as a multi-faceted process, a team effort, and an essential ingredient for guideline adaptation. While front-line care providers implicitly identified implementation issues during adaptation, they identified a need to add an explicit implementation planning component. Conclusions: Guideline adaptation is a positive initial step toward evidence-informed care, but adaptation (vs. 'de novo' development) did not meet expectations for reducing time or resource commitments. Undertaking adaptation is as much about the process (engagement and capacity building) as it is about the product (adapted guideline). To adequately address local concerns, cases found it necessary to also search and appraise primary studies, resulting in hybrid (adaptation plus de novo) guideline development strategies that required advanced methodological skills.Adaptation was found to be an action element in the knowledge translation continuum that required integration of an implementation perspective. Accordingly, the adaptation methodology and resources were reformulated and substantially augmented to provide practical assistance to groups not supported by a dedicated guideline panel and to provide more implementation planning support. The resulting framework is called CAN-IMPLEMENT. http://www.implementationscience.com/content/8/1/49 Margaret Harrison Ian Graham Joan van den Hoek Elizabeth Dogherty Meg Carley Valerie Angus Implementation Science 2013, null:49 2013-05-08T00:00:00Z doi:10.1186/1748-5908-8-49 /content/figures/1748-5908-8-49-toc.gif Implementation Science 1748-5908 ${item.volume} 49 2013-05-08T00:00:00Z PDF Background: In high-resource settings, 'pay-for-performance' (P4P) programs have generated interest as a potential mechanism to improve health service delivery and accountability. However, there has been little or no experimental evidence to guide the development or assess the effectiveness of P4P incentive programs in developing countries. In the developing world, P4P programs are likely to rely, at least initially, on external funding from donors. Under these circumstances, the sustainability of such programs is in doubt and needs assessment. Methods: We describe a cluster-randomized controlled trial underway in 18 health centers in western Kenya that is testing an innovative incentive strategy to improve management of an epidemiologically and economically important problem---diagnosis and treatment of malaria. The incentive scheme in this trial promotes adherence to Ministry of Health guidelines for laboratory confirmation of malaria before treatment, a priority area for the Ministry of Health. There are three important innovations that are unique to this study among those from other resource-constrained settings: the behavior being incentivized is quality of care rather than volume of service delivery; the incentives are applied at the facility-level rather than the individual level, thus benefiting facility infrastructure and performance overall; and the incentives are designed to be budget-neutral if effective.DiscussionLinking appropriate case management for malaria to financial incentives has the potential to improve patient care and reduce wastage of expensive antimalarials. In our study facilities, on average only 25% of reported malaria cases were confirmed by laboratory diagnosis prior to the intervention, and the total treatment courses of antimalarials dispensed did not correspond to the number of cases reported. This study will demonstrate whether facility rather than individual incentives are compelling enough to improve case management, and whether these incentives lead to offsetting cost-savings as a result of reduced drug consumption.Trial registrationClinicalTrials.gov Registration Number NCT01809873 http://www.implementationscience.com/content/8/1/48 Diana Menya John Logedi Imran Manji Janice Armstrong Brian Neelon Wendy O¿Meara Implementation Science 2013, null:48 2013-05-08T00:00:00Z doi:10.1186/1748-5908-8-48 /content/figures/1748-5908-8-48-toc.gif Implementation Science 1748-5908 ${item.volume} 48 2013-05-08T00:00:00Z PDF Background: Computer reminders are increasingly being applied in efforts to improve quality and patient safety. However, research is still needed to establish the effectiveness of different kinds of reminders in various settings. This study aimed to evaluate the effectiveness of computer reminders for improving adherence to a quality assessment scheme for point-of-care testing in general practice.MethodThe study was conducted as a randomized controlled crossover trial among general practices in the Capital Region of Denmark. The intervention consisted of sending computer reminders (ComRem) to practices not adhering to the guideline recommendations of split testing for hemoglobin and glucose. Practices were randomly allocated into two groups. During the first follow-up period, one of the groups received the ComRem intervention together with the general implementation activities (GIA), while the other group only received the GIA. For the second follow-up period, the intervention was switched between the two groups. Outcomes were measured as split test procedure adherence. Results: A total of 142 practices were randomly allocated to the early intervention group and 144 practices to the late intervention group (the control group in the first follow-up period). In the first intervention period, the mean number of split tests performed in the group receiving ComRem group increased from 1.22 to 3.76 (out of eight possible tests) while the mean number of split tests increased from 1.11 to 2.35 in the group targeted by GIA only (p = 0.0059). After the crossover, a similar effect of reminders was observed. Furthermore, the developments in outcome measures over time showed a strong effect of computer reminders beyond the intervention periods. Conclusion: There was a significant effect of computer reminders on adherence to the quality assessment scheme for point-of-care testing. Thus, computer reminders seem to be useful for supporting the implementation of relatively simple procedures for quality and safety.Trial registrationClinicalTrials.gov: http://NCT01152177 http://www.implementationscience.com/content/8/1/47 Marius Kousgaard Volkert Siersma Susanne Reventlow Ruth Ertmann Peter Felding Frans Waldorff Implementation Science 2013, null:47 2013-04-23T00:00:00Z doi:10.1186/1748-5908-8-47 /content/figures/1748-5908-8-47-toc.gif Implementation Science 1748-5908 ${item.volume} 47 2013-04-23T00:00:00Z XML Background: Childhood obesity is a ‘wicked’ public health problem that is best tackled by an integrated approach, which is enabled by integrated public health policies. The development and implementation of such policies have in practice proven to be difficult, however, and studying why this is the case requires a tool that may assist local policy-makers and those assisting them. A comprehensive framework that can help to identify options for improvement and to systematically develop solutions may be used to support local policy-makers.DiscussionWe propose the ‘Behavior Change Ball’ as a tool to study the development and implementation of integrated public health policies within local government. Based on the tenets of the ‘Behavior Change Wheel’ by Michie and colleagues (2011), the proposed conceptual framework distinguishes organizational behaviors of local policy-makers at the strategic, tactical and operational levels, as well as the determinants (motivation, capability, opportunity) required for these behaviors, and interventions and policy categories that can influence them. To illustrate the difficulty of achieving sustained integrated approaches, we use the metaphor of a ball in our framework: the mountainous landscapes surrounding the ball reflect the system’s resistance to change (by making it difficult for the ball to roll). We apply this framework to the problem of childhood obesity prevention. The added value provided by the framework lies in its comprehensiveness, theoretical basis, diagnostic and heuristic nature and face validity.SummarySince integrated public health policies have not been widely developed and implemented in practice, organizational behaviors relevant to the development of these policies remain to be investigated. A conceptual framework that can assist in systematically studying the policy process may facilitate this. Our Behavior Change Ball adds significant value to existing public health policy frameworks by incorporating multiple theoretical perspectives, specifying a set of organizational behaviors and linking the analysis of these behaviors to interventions and policies. We would encourage examination by others of our framework as a tool to explain and guide the development of integrated policies for the prevention of wicked public health problems. http://www.implementationscience.com/content/8/1/46 Anna-Marie Hendriks Maria Jansen Jessica Gubbels Nanne De Vries Theo Paulussen Stef Kremers Implementation Science 2013, null:46 2013-04-18T00:00:00Z doi:10.1186/1748-5908-8-46 /content/figures/1748-5908-8-46-toc.gif Implementation Science 1748-5908 ${item.volume} 46 2013-04-18T00:00:00Z XML