Browsing by Subject "Implementation science"
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Item A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury(Springer Nature, 2024-08-05) Tignanelli, Christopher J.; Shah, Surbhi; Vock, David; Siegel, Lianne; Serrano, Carlos; Haut, Elliott; Switzer, Sean; Martin, Christie L.; Rizvi, Rubina; Peta, Vincent; Jenkins, Peter C.; Lemke, Nicholas; Thyvalikakath, Thankam; Osheroff, Jerome A.; Torres, Denise; Vawdrey, David; Callcut, Rachael A.; Butler, Mary; Melton, Genevieve B.; Surgery, School of MedicineBackground: Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation. Methods: The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system. Discussion: The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.Item Agile Implementation of a Digital Cognitive Assessment for Dementia in Primary Care(Annals of Family Medicine, 2025-05-27) Summanwar, Diana; Fowler, Nicole R.; Hammers, Dustin B.; Perkins, Anthony J.; Brosch, Jared R.; Willis, Deanna R.; Family Medicine, School of MedicinePurpose: This study aimed to assess how agile implementation-driven iterative processes and tailored workflows can facilitate the implementation of a digital cognitive assessment (DCA) tool for patients aged 65 years or older into primary care practices. Methods: We used agile implementation principles to integrate a DCA tool into routine workflows across 7 primary care clinics. The intervention involved a structured selection process for identifying an appropriate DCA tool, stakeholder engagement through iterative sprints (structured, time-bound cycles), and development of tailored workflows to meet clinic-specific needs. A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the intervention's performance over a 12-month period. Results: The intervention engaged 69 (63.8%) of 108 clinicians across the 7 clinics. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. We selected the Linus Health Core Cognitive Evaluation tool as our DCA tool based on stakeholder evaluations. Screening workflows were tailored to each clinic. The brain health navigator received 447 referrals for further assessment of a positive or borderline screening result. Four clinics fully adopted the intervention, achieving a DCA completion rate of at least 20%, and 5 clinics were still routinely using the DCA tool at 12 months. Conclusions: Agile implementation effectively helped integrate the DCA tool into primary care workflows. Customized workflows, stakeholder engagement, and iterative improvements were crucial for adoption and sustainability. These insights can guide future efforts for early detection and management of cognitive impairment in primary care, ultimately improving patient outcomes and easing the burden on health care professionals.Item Barriers and facilitators to mental health promotion for Mexican immigrants in the U.S. through the Ventanillas de Salud program(Frontiers Media, 2023-09-28) González Casanova, Inés; Martínez Rodriguez, Delia Lilian; Ortiz Brunel, Julissa; Rangel Gómez, María Gudelia; de Groot, Mary; Fernández, Alicia; Medicine, School of MedicineIntroduction: Mental health promotion and screenings are recommended as part of standard preventive care. Mexican immigrants in the U.S. are at high risk for mental health illness especially after the COVID-19 pandemic, however access to mental health prevention for this population has been limited, which results in important implementation and equity gaps. The Ventanilla de Salud (VDS) program provides preventive services through Mexican consulates in the U.S. Objective: The objective of this study was to assess capability, opportunity, and motivation for promotores to implement mental health programming through the VDS, leveraging early experiences of ongoing mental health prevention efforts. Methods: This was a qualitative study using the Capability, Opportunity, and Motivation for Behavior Change model (COM-B). We conducted 9 focus groups with 40 VDS promotores and 6 semi-structured interviews with program stakeholders. Data were analyzed using inductive and deductive coding. Results: We found high levels of interest from the leadership, partners, and promotores to provide mental health services through the VDS. Early implementation of a mental health strategy that included training sessions for promotores and mental health promotion, screenings and referrals for VDS users was ongoing. We identified facilitators and barriers that could affect capability, opportunity, and motivation to provide mental health services. Facilitators included promotores' extensive knowledge about the importance of mental health, promotores service mindset and commitment to provide services to VDS users, and general support from the VDS network and partners. Barriers included promotores' turnover, need for additional economic compensation, burnout, competing priorities, and lack of mental health professionals to provide clinical services or supervision. Additional investments are recommended to support promotores' well-being. Conclusion: The main lesson learned from this study was that investing in VDS promotores' training, resources, and well-being is key to their capability, opportunity and motivation to provide mental health services for Mexican immigrants in the US. Results from this study can be applied to improve the ongoing VDS mental health strategy and increase its impact on the mental health of Mexican immigrants.Item Closing the Tobacco Treatment Gap: A Qualitative Study of Tobacco Cessation Service Implementation in Community Pharmacies(MDPI, 2024-03-28) Ellis Hilts, Katy; Elkhadragy, Nervana; Corelli, Robin L.; Hata, Micah; Tong, Elisa K.; Vitale, Francis M.; Suchanek Hudmon, Karen; Health Policy and Management, Richard M. Fairbanks School of Public HealthTobacco use remains a leading preventable cause of morbidity and mortality, with pharmacotherapy and counseling recognized as effective cessation aids. Yet, the potential role of pharmacists and pharmacy technicians in tobacco cessation services is underutilized. This study explores the integration of such services in community pharmacies, identifying facilitators and barriers to their implementation. A qualitative study was conducted across seven community pharmacies in California that were affiliated with the Community Pharmacy Enhanced Services Network. Participants included 22 pharmacists and 26 pharmacy technicians/clerks who completed tobacco cessation training. Data were collected through semi-structured interviews, focusing on experiences with implementing cessation services. The analysis was guided by Rogers' Diffusion of Innovations Theory. MAXQDA software was used for data management and thematic analysis. Sixteen pharmacy personnel participated in the study, highlighting key themes around the integration of cessation services. Compatibility with existing workflows, the importance of staff buy-in, and the crucial role of pharmacy technicians emerged as significant facilitators. Challenges included the complexity of billing for services, software limitations for documenting tobacco use and cessation interventions, and gaps in training for handling complex patient cases. Despite these barriers, pharmacies successfully initiated cessation services, with variations in service delivery and follow-up practices. Community pharmacies represent viable settings for delivering tobacco cessation services, with pharmacists and technicians playing pivotal roles. However, systemic changes are needed to address challenges related to billing, documentation, and training. Enhancing the integration of cessation services in community pharmacies could significantly impact public health by increasing access to effective cessation support.Item Cohort profile: measuring adverse pregnancy and newborn congenital outcomes (MANGO) study in Kenya(BMJ, 2025-04-30) Humphrey, John M.; Chepkemoi, Audrey; Brown, Steven; Carlucci, James G.; McPheron, Molly; Kerich, Caroline; Matelong, Winnie; Kooreman, Harold; McHenry, Megan S.; Bernard, Caitlin; Kiano, Marylydia; Musick, Beverly S.; Yiannoutsos, Constantin T.; Wools-Kaloustian, Kara; Patel, Rena C.; Were, Edwin; EA-IeDEA consortium; Medicine, School of MedicinePurpose: Pharmacovigilance (PV) systems to assess the safety of antiretroviral treatment used periconception and during pregnancy are lacking in low-resource settings with high HIV burdens, and strategies to guide their implementation are limited. We implemented the Measuring Adverse Pregnancy and Newborn Congenital Outcomes (MANGO) study in Kenya to address these gaps. Participants: In MANGO, we ascertained delivery outcomes for pregnant women living with HIV (WLH) and not living with HIV (WNLH) enrolled in care at Moi Teaching and Referral Hospital (MTRH) through two cohorts: C1, a prospective cohort of 1:1 matched WLH and WNLH attending antenatal clinic; and C2, a cross-sectional cohort of all deliveries, including among those who did not attend antenatal clinic at MTRH. Findings to date: 24 205 deliveries were recorded from October 2020 to September 2023 (853 in C1 and 23 352 in C2). Median maternal age was 32 years, 4.5% were WLH and 2.6% of deliveries were stillbirths. Among liveborn infants, 17.2% were preterm (<37 weeks), and 15.1% were low birth weight (<2.5 kg). Prevalence of ≥1 major congenital abnormality was 73.9/10 000 births (47.7 in C1 and 76.1 in C2). Assessing implementation barriers/facilitators, lack of national PV policy was a barrier overcome through establishing partnerships with the Kenya Ministry of Health. The facility's size and complexity were barriers to newborn surface exam coverage overcome through staff training and cocreation of a standardised form for newborn surface exam documentation. High staff turnover was addressed by involving head nurses to champion implementation and incentivising staff participation with medical education credits. Use of audit/feedback cycles and focusing on PV as a way to improve care quality facilitated PV institutionalisation at MTRH. Future plans: The MANGO model is a multifaceted strategy with replicative potential in other settings. Research is needed to understand the model's opportunities for implementation in other settings.Item Coming back for more: factors linked to higher participation among Veterans with chronic pain in an innovative VA-YMCA wellness clinic(BMJ, 2024-01-29) Preddie, Alaina K.; Donnelly, Claire E.; Miech, Edward J.; Myers, Laura J.; Williams, Linda S.; Damush, Teresa M.; Medicine, School of MedicineIn 2019, the Indianapolis VA developed a Wellness Clinic in partnership with the Young Men's Christian Associations (YMCA) to comprehensively address Veterans' chronic pain. Our specific aims were twofold: (1) to evaluate the implementation of the Veterans Health Indiana (VHI) Wellness Clinic on patient utilisation and (2) to evaluate patient functioning.We conducted a mixed-methods evaluation, which included the extraction of VA administrative data to identify a patient cohort; the conduct of chart review to extract clinic utilisation, clinical outcomes collected during pain-related healthcare services and comorbidities; and semistructured interviews with Veteran patients who used the VHI Wellness Clinic in different patterns to identify challenges and facilitators to clinic utilisation. We applied configurational analysis to a Veteran sample who had their first visit to the VHI Wellness Clinic in March/April 2019 to pinpoint difference-making factors linked to Veterans' successful participation.The cohort included 312 Veterans (83% male), mean age of 55.4 years. The configurational model included six factors: participation in physical therapy, pain psychology or pain education sessions (22%); presence of any 'no-shows' (57% had 0); history of depression (39%) and clinic referral source (51% self-referred from primary care). The model consisted of four different pathways to successful participation, explaining 60% of cases in the higher-participation group with 86% consistency. Patient outcomes after clinic utilisation demonstrated a significant reduction in self-reported pain and pain catastrophising across time. Moreover, patients reported distance to clinic as both a facilitator and challenge.This mixed-methods analysis identified specific biopsychosocial factors and clinical services directly linked to higher Veteran participation in a new VA-YMCA Wellness Clinic. The VHI Wellness Clinic embedded within a YMCA facility is a feasible and efficacious healthcare delivery model for primary care patients experiencing chronic pain. Additional marketing to clinical providers for referrals and to patients to extend its reach is needed.Item Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study(American College of Physicians, 2022) Marcantonio, Edward R.; Fick, Donna M.; Jung, Yoojin; Inouye, Sharon K.; Boltz, Marie; Leslie, Douglas L.; Husser, Erica K.; Shrestha, Priyanka; Moore, Amber; Sulmonte, Kimberlyann; Siuta, Jonathan; Boustani, Malaz; Ngo, Long H.; Medicine, School of MedicineBackground: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. Objective: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). Design: Prospective cohort study. Setting: Large urban academic medical center and small rural community hospital. Participants: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). Measurements: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. Results: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). Limitation: Two sites; limited diversity. Conclusion: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists.Item Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014(Wiley, 2017-01-06) Fritz, Cristin Q.; Blevins, Meridith; Lindegren, Mary Lou; Wools-Kaloutsian, Kara; Musick, Beverly S.; Cornell, Morna; Goodwin, Kelly; Addison, Dianne; Dusingize, Jean Claude; Messou, Eugène; Poda, Armel; Duda, Stephany N.; McGowan, Catherine C.; Law, Matthew G.; Moore, Richard D.; Freeman, Aimee; Nash, Denis; Wester, C. William; Medicine, School of MedicineINTRODUCTION: An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey. METHODS: Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care. RESULTS: The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44-100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001). CONCLUSION: The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported).Item Core implementation strategies for improving cirrhosis care in the Veterans Health Administration(Wolters Kluwer, 2022) Yakovchenko, Vera; Morgan, Timothy R.; Miech, Edward J.; Neely, Brittney; Lamorte, Carolyn; Gibson, Sandra; Beste, Lauren A.; McCurdy, Heather; Scott, Dawn; Gonzalez, Rachel; Park, Angela; Powell, Byron J.; Bajaj, Jasmohan S.; Dominitz, Jason A.; Chartier, Maggie; Ross, David; Chinman, Matthew J.; Rogal, Shari S.; Emergency Medicine, School of MedicineBackground and aims: The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. Approach and results: VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. Conclusions: In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.Item Correction: Opportunities to implement a sustainable genomic medicine program: lessons learned from the IGNITE Network(Springer Nature, 2019-07) Levy, Kenneth D.; Blake, Kathryn; Fletcher-Hoppe, Colette; Franciosi, James; Goto, Diasuke; Hicks, James K.; Holmes, Ann M.; Kanuri, Sri Harsha; Madden, Ebony B.; Musty, Michael D.; Orlando, Lori; Pratt, Victoria M.; Ramos, Michelle; Wu, Ryanne; Ginsburg, Geoffrey S.; Medicine, School of MedicineThe original version of this Article contained an error in the spelling of the author Geoffrey S. Ginsburg, which was incorrectly given as Geoffrey Ginsburg. This has now been corrected in both the PDF and HTML versions of the Article.