The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop

Albert L Siu,Sara Lubetsky,Elisse Catalan,Alex D Federman,Melissa Garrido,Barbara Morano,Bruce Leff,Robert M Zimbroff,Linda V Decherrie

doi:10.1186/s12913-019-4063-8

Abstract

BackgroundTranslating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from “voltage drop” (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or “program drift.” (decreased benefit arising from deviations from study protocols).MethodsPatients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics.ResultsAdaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11–44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (− 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66).ConclusionsWe made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential ‘program drift’ or ‘voltage drop.’Trial registrationNot applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study “in which the assignment of the medical intervention is not at the discretion of the investigator.”

Highlights

Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation
This effect has been termed “program drift” and “voltage drop” [3]
Some adaptations may enhance the effectiveness of the original intervention3, thereby neutralizing any diminished effectiveness from program drift or voltage drop or perhaps even increasing the net benefit beyond that observed in evidence-based studies

Summary

Introduction

Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. It has been thought that variance from an evidence-based protocol is accompanied with at least some diminution of effectiveness This effect has been termed “program drift” (i.e., decreased benefit arising from deviations from study protocols) and “voltage drop” (i.e., loss of benefit when interventions are applied in more heterogeneous patient populations and settings as they move from efficacy to effectiveness and into actual practice) [3]. Other adaptations may address technological or medical advances that were not available or formally manualized at the time of the evidence-based study In theory, these adaptations may have neutral effects. Some adaptations may enhance the effectiveness of the original intervention, thereby neutralizing any diminished effectiveness from program drift or voltage drop or perhaps even increasing the net benefit beyond that observed in evidence-based studies. Some have called for the systematic study of adaptations to evidence-based interventions and a formalized structure for updating the evidence base to account for adaptation [4]

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Results

Conclusion