Browsing by Subject "Implementation outcomes"

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    Facility-level conditions leading to higher reach: a configurational analysis of national VA weight management programming
    (Springer Nature, 2021-08-11) Miech, Edward J.; Freitag, Michelle B.; Evans, Richard R.; Burns, Jennifer A.; Wiitala, Wyndy L.; Annis, Ann; Raffa, Susan D.; Spohr, Stephanie A.; Damschroder, Laura J.; Emergency Medicine, School of Medicine
    Background: While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach. Methods: A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of "new" MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates. Results: One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47). Conclusions: Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE!
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    Integration and evaluation of implementation strategies to improve guideline-concordant bladder cancer surveillance: a prospective observational study
    (Springer Nature, 2025-04-07) Zubkoff, Lisa; Ould Ismail, A. Aziz; Jensen, Laura; Haggstrom, David A.; Kale, Soham; Issa, Muta M.; Tosoian, Jeffrey J.; Siddiqui, Mohummad Minhaj; Bloomquist, Kennedi; Kimball, Elisabeth R.; Zickmund, Susan; Schroeck, Florian R.; Medicine, School of Medicine
    Background: Despite guideline recommendations, our prior work revealed more than half of low-risk bladder cancer patients within the Department of Veterans Affairs (VA) undergo too many surveillance procedures and about a third of high-risk patients do not undergo enough procedures. Thus, we developed and integrated implementation strategies to improve risk-aligned bladder cancer surveillance for the VA. Methods: Prior work used Implementation Mapping to develop nine implementation strategies: change record systems, educational meetings, champions, tailoring, preparing patients to be active participants, external facilitation, remind clinicians, audit & feedback, and a blueprint. We integrated these strategies as improvement approaches across four VA urology clinics. Primary implementation outcomes were qualitatively measured via coding of semi-structured interviews with clinicians and co-occurrence of codes. Implementation outcomes included: appropriateness, acceptability, and feasibility. Exploratory quantitative outcomes included clinicians' recommendations for guideline-concordant bladder cancer surveillance intervals and sustainability. Results: Eleven urologists were interviewed. Co-occurrence analysis of codes across strategies indicated that urologists most commonly reported on the acceptability and appropriateness of changing the record system, preparing patients to be active participants ("surveillance grid"), reminders (i.e., cheat sheet), and educational sessions. We confirmed feasibility of all implementation strategies. Urologists indicated that changing the record system had a high impact, reduced documentation time, and guided resident physicians. Preparing patients to be active participants using the "surveillance grid" was seen as an effective but time-consuming tool. Educational sessions were seen as critical to support implementation. In quantitative analyses, clinicians recommended guideline-concordant surveillance about 65% of the time at baseline for low-risk patients, and this improved to 70% during evaluation. Across all risk levels, the largest improvement was observed at site 2 while site 3 did not improve. All sites sustained use of the changed record system, while sustainability of other strategies was variable. Conclusions: Based on summative interpretation of results, the most appropriate, acceptable, and feasible strategies include changing record systems via a template and educational meetings focused on guideline-concordant surveillance. Future work should assess the impact of the improvement approaches on clinical care processes, particularly on reducing overuse of surveillance procedures among low-risk patients.