Development of a blended learning approach to delivering HIV assisted contact tracing in Malawi: applied theory and formative research (Preprint)

UNSTRUCTURED Despite progress towards the UNAIDS “95-95-95” targets (95% of HIV-positive persons tested, 95% of tested persons on treatment, and 95% of treated persons virally suppressed), a gap remains in achieving the first 95% target. Assisted contact tracing (ACT), in which health workers support HIV-positive indexes to recruit their contacts (sexual partners and children) for HIV testing, efficiently identify HIV-positive persons in need of treatment. ACT is recommended in the World Health Organization’s 2016 guidance, and although many countries, including Malawi, began implementing ACT, testing outcomes in routine settings have been worse than those in trial settings. To bridge the gap between research and practice and support scale-up in Malawi, a set of implementation strategies (“implementation package”) was developed using frameworks and theories. First, the Consolidated Framework for Implementation Research (CFIR) guided qualitative research to identify key barriers and facilitators to intervention delivery. Limited clinic coordination and health worker capacity to address the complexities of ACT were identified as key barriers; ongoing individual training and group problem-solving were identified as facilitators. Next, the theory of expertise, social cognitive theory and principles of continuous quality improvement informed the development of the implementation package to address these barriers and facilitators. Finally, human-centered design principles guided the translation of the implementation package from in-person to digital delivery. This trajectory highlights the key roles behavioral theories, implementation frameworks, and technology can play in bringing an evidence-based intervention, such as ACT, to scale in a low-income setting like Malawi.

Efficacy of an implementation package on documentation of central venous catheter insertions: an observational study

BackgroundProper documentation of central venous catheter (CVC) insertions in electronic healthcare records is the basis for good follow-up and quality assurance. We have noted serious deficiencies in the documentation of CVC insertions and introduced an implementation package with the purpose of increasing the completeness of this documentation. The aim of the present study was to estimate the effect of the implementation package by assessing the proportion of missing data before and after the introduction of the implementation package.MethodsIn this single centre observational study, data from CVC insertion templates in a common electronic health record were extracted and analysed after introducing the implementation package. The package included adoption of new local CVC-directions, a new updated CVC-insertion template in the regional common electronic health record and a review of all CVC-insertion templates with a reminder to the inserting physician to supplement missing data. The proportion of terms with missing data was reviewed and also compared with the proportion of missing data in a study prior to the introduction of the package.ResultsIn total, 7126 CVC-insertion templates were included. Of these 5539 (78%) were without missing data for any of the 13 predefined variables. Completed insertion templates for three common terms increased from 38% prior to the introduction of the implementation package to 93%, which represents an absolute reduction for missing data of 55% (95% CI 53% to 56%, p<0.0001).ConclusionThe implementation package was highly effective in increasing the proportion of fully documented CVC insertions.

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system

Objectives To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up. Design Following the Replicating Effective Programs framework, we analyzed content from implementation teams’ focus groups, local and cross-site meeting minutes and sites’ organizational profiles to develop an implementation package. Setting Three academic emergency departments that each implemented EQUIPPED over three successive years. Participants Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects. Intervention(s) EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge. Main Outcome Measure(s) Implementation process components assembled through successive implementation. Results Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model. Conclusions Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

What is the feasibility and observed effect of two implementation packages for stroke rehabilitation therapists implementing upper limb guidelines? A cluster controlled feasibility study

BackgroundHand and arm activity after stroke improves with evidence-based rehabilitation. Therapists face known barriers when providing evidence-based rehabilitation and require support to implement guidelines. The aim of this study was to investigate the feasibility of two implementation packages on guideline adherence by occupational therapists and physiotherapists, and explore effect on patient upper limb outcomes.MethodThis was a non-randomised clustered feasibility study of occupational and physiotherapy rehabilitation services (n=3 inpatient and n=3 outpatient services). Services were allocated to one of three groups: (group A) facilitator-mediated implementation package, (group B) self-directed implementation package or (group C) usual care (control); we recruited n=1 inpatient and n=1 outpatient service per group. Outcomes of feasibility, adherence to guidelines (medical file audits) and patient upper limb impairment (Fugl-Meyer Upper Extremity Assessment), activity (Box and Block Test) and practice (minutes/week) were collected at baseline and after 3 months of intervention.Results29 therapists (8 in group A, 13 in groups B and 8 in group C) and 55 patients participated. Both the facilitator-mediated and the self-directed implementation packages were feasible to deliver in the rehabilitation setting. Therapists in group A improved with respect to guideline adherence (medical file audits; median within-group proportion difference of 0.29 (95% CI 0.22 to 0.36, p<0.0001) preintervention to postintervention). No significant within-group differences from baseline to postintervention were found in group B or group C, and no between-group differences were found for upper limb outcomes.ConclusionA facilitator-mediated package was acceptable to therapists working in stroke rehabilitation, and feasibility data suggest increased guideline uptake following implementation. An adequately powered study is planned to understand how to support therapists to provide evidence-based upper limb rehabilitation after stroke.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12619000596101).

Developing and evaluating packages to support implementation of quality indicators in general practice: the ASPIRE research programme, including two cluster RCTs

Background Dissemination of clinical guidelines is necessary but seldom sufficient by itself to ensure the reliable uptake of evidence-based practice. There are further challenges in implementing multiple clinical guidelines and clinical practice recommendations in the pressurised environment of general practice. Objectives We aimed to develop and evaluate an implementation package that could be adapted to support the uptake of a range of clinical guideline recommendations and be sustainably integrated within general practice systems and resources. Over five linked work packages, we developed ‘high-impact’ quality indicators to show where a measurable change in clinical practice can improve patient outcomes (work package 1), analysed adherence to selected indicators (work package 2), developed an adaptable implementation package (work package 3), evaluated the effects and cost-effectiveness of adapted implementation packages targeting four indicators (work package 4) and examined intervention fidelity and mechanisms of action (work package 5). Setting and participants Health-care professionals and patients from general practices in West Yorkshire, UK. Design We reviewed recommendations from existing National Institute for Health and Care Excellence clinical guidance and used a multistage consensus process, including 11 professionals and patients, to derive a set of ‘high-impact’ evidence-based indicators that could be measured using routinely collected data (work package 1). In 89 general practices that shared data, we found marked variations and scope for improvement in adherence to several indicators (work package 2). Interviews with 60 general practitioners, practice nurses and practice managers explored perceived determinants of adherence to selected indicators and suggested the feasibility of adapting an implementation package to target different indicators (work package 3). We worked with professional and patient panels to develop four adapted implementation packages. These targeted risky prescribing involving non-steroidal anti-inflammatory and antiplatelet drugs, type 2 diabetes control, blood pressure control and anticoagulation for atrial fibrillation. The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. We randomised 178 practices to implementation packages targeting either diabetes control or risky prescribing (trial 1), or blood pressure control or anticoagulation (trial 2), or to a further control (non-intervention) group, and undertook economic modelling (work package 4). In trials 1 and 2, practices randomised to the implementation package for one indicator acted as control practices for the other package, and vice versa. A parallel process evaluation included a further eight practices (work package 5). Main outcome measures Trial primary end points at 11 months comprised achievement of all recommended levels of glycated haemoglobin, blood pressure and cholesterol; risky prescribing levels; achievement of recommended blood pressure; and anticoagulation prescribing. Results We recruited 178 (73%) out of 243 eligible general practices. We randomised 80 practices to trial 1 (40 per arm) and 64 to trial 2 (32 per arm), with 34 non-intervention controls. The risky prescribing implementation package reduced risky prescribing (odds ratio 0.82, 97.5% confidence interval 0.67 to 0.99; p = 0.017) with an incremental cost-effectiveness ratio of £2337 per quality-adjusted life-year. The other three packages had no effect on primary end points. The process evaluation suggested that trial outcomes were influenced by losses in fidelity throughout intervention delivery and enactment, and by the nature of the targeted clinical and patient behaviours. Limitations Our programme was conducted in one geographical area; however, practice and patient population characteristics are otherwise likely to be sufficiently diverse and typical to enhance generalisability to the UK. We used an ‘opt-out’ approach to recruit general practices to the randomised trials. Subsequently, our trial practices may have engaged with the implementation package less than if they had actively volunteered. However, this approach increases confidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions. Conclusions This pragmatic, rigorous evaluation indicates the value of an implementation package targeting risky prescribing. In broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators. Future work There are challenges in designing ‘one-size-fits-all’ implementation strategies that are sufficiently robust to bring about change in the face of difficult clinical contexts and fidelity losses. We recommend maximising feasibility and ‘stress testing’ prior to rolling out interventions within a definitive evaluation. Our programme has led on to other work, adapting audit and feedback for other priorities and evaluating different ways of delivering feedback to improve patient care. Trial registration Current Controlled Trials ISRCTN91989345. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

A cluster-randomised evaluation of an adaptable implementation strategy targeting ‘high impact’ indicators in primary care

BackgroundRecognised gaps between evidence and practice in primary care present particular implementation challenges when addressing multiple priorities.AimTo evaluate the effectiveness of a multifaceted, adaptable implementation package targeting four different ‘high impact’ indicators.MethodWe undertook two parallel, pragmatic cluster randomised trials using balanced incomplete block designs with parallel process evaluation. General practices in West Yorkshire, UK, were recruited using an ‘opt out’ process. The adaptable implementation package included audit and feedback, educational outreach visits and computerised support with embedded behaviour change techniques tailored to each indicator. Practices were randomised to packages targeting either type 2 diabetes control or risky prescribing of non-steroidal anti-inflammatory drugs, or packages targeting either anticoagulation in atrial fibrillation or blood pressure control in patients at high risk of cardiovascular events. Respective primary endpoints comprised: achievement of all recommended levels of haemoglobin A1c, blood pressure and cholesterol; risky prescribing levels; anticoagulation prescribing; and achievement of recommended blood pressure levels. Outcomes at 11 months used routinely collected data.Results178 out of 244 eligible practices participated. The implementation package reduced risky prescribing (odds ratio 0.82; 97.5% confidence interval 0.67 to 0.99). There was no effect on other primary endpoints.ConclusionThis highly pragmatic, robust evaluation suggests the value of targeting risky prescribing, given predictable population reductions in avoidable morbidity, deaths and hospital admissions. However, in broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators.