Abstract
PurposeFew evidence-based strategies are specifically tailored for disparity populations such as rural adults. Two-way video-conferencing using telemedicine can potentially surmount geographic barriers that impede participation in high-intensity treatment programs offering frequent visits to clinic facilities. We aimed to understand barriers and facilitators of implementing a telemedicine-delivered tertiary-care, rural academic weight-loss program for the management of obesity.MethodsA single-arm study of a 16-week, weight-loss pilot evaluated barriers and facilitators to program participation and exploratory measures of program adoption and staff confidence in implementation and intervention delivery. A program was delivered using video-conferencing within an existing clinical infrastructure. Elements of Consolidated Framework for Implementation Research (CFIR) provided a basis for assessing intervention characteristics, inner and outer settings, and individual characteristics using surveys and semi-structured interviews. We evaluated elements of the RE-AIM model (reach, adoption) to assess staff barriers to success for future scalability.FindingsThere were 27 patients and 8 staff completing measures. Using CFIR, the intervention was valuable from a patient participant standpoint; staff equally had positive feelings about using telemedicine as useful for patient care. The RE-AIM framework demonstrated limited reach but willingness to adopt was above average. A significant barrier limiting sustainability was physical space for intervention delivery and privacy and dedicated resources for staff. Scheduling stressors were also a challenge in its implementation.ConclusionsThe need to engage staff, enhance organizational culture, and increase reach are major factors for rural health obesity clinics to enhance sustainability of using telemedicine for the management of obesity.Trial registrationClinicaltrials.gov NCT03309787. Registered on 16 October 2017.
Highlights
Tertiary care weight management clinics located at academic medical centers usually serve patients from large geographic areas
Technology-delivered care can be helpful in scaling interventions for rural adults with obesity residing in remote areas
Enhancing patient/staff engagement and culture can overcome organizational stress and enhance reach of the intervention the Consolidated Framework for Implementation Research (CFIR) and RE-AIM [5]. These frameworks have previously been applied in the context of telemedicine and have found that patient and leadership engagement, comfort levels with the technology, and a need to have similar efficacy and workflows to in-person visits were important factors [6,7,8]
Summary
Tertiary care weight management clinics located at academic medical centers usually serve patients from large geographic areas. Recognizing the need for different models of health service delivery, we conducted a pragmatic clinical pilot trial within our weight-management clinic aimed at providing usual clinical care using two-way, live, telemedicine. Our results were proven to be feasible, acceptable, and potentially effective at producing weight loss [4]; yet, this delivery system (telemedicine) could potentially lead to inherent challenges for both patient and provider stakeholders. Successful implementation of evidence-based practices requires an understanding of the barriers and facilitators of implementing new services. Two wellrecognized frameworks for exploring implementation factors, barriers/enablers that permit planning, evaluating practice change interventions, and why implementation succeeded or not to identify modifiable factors, are
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