Promoting Action On Research Implementation In Health Services Research Articles

Algo's Integrated Knowledge Translation Process in Homecare Services: A Cross-Sectional Correlational Study for Identifying its Level of Utilization and its Associated Characteristics.

Background. Algo is an integrated knowledge translation (IKT)-based algorithm for supporting occupational therapists (OTs) with skill mix for selecting bathing equipment. While IKT approaches are increasingly valued in implementation science, their benefits with respect to the utilization of knowledge in clinical settings are scarcely documented. Purpose. To identify Algo's level of utilization and the characteristics associated with its level of utilization. Method. A cross-sectional correlational study was conducted with OTs working in homecare services (HCS) through an online survey based on Knott and Wildavsky's classification and the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Findings. Almost half (48%) of the OTs surveyed (n = 125; participation rate: 16%) reached one of the seven levels of utilization. While Evidence characteristics are perceived as facilitators to its utilization, Context statements indicate an unfavorable organizational climate to the implementation of change. Implications. Strategies should target additional stakeholders (e.g., HCS managers) and organizational adjustments in HCS to sustain Algo's utilization.

Design and baseline results of a coaching intervention for implementation of trans-radial access in percutaneous coronary intervention

Trans-radial artery access (TRA) for cardiac catheterization and percutaneous coronary intervention has many advantages over trans-femoral artery access (TFA), but implementation has been slow. The steep learning curve, logistical issues, and radiation exposure have been documented as barriers to implementation. Although many cardiac catheterization laboratories have overcome these barriers, we lack evidence on effective implementation strategies. Our objective is to test a team-based coaching intervention that targets the learning curve and other barriers to increase use of TRA. We use a stepped-wedge cluster-randomized trial to test a coaching intervention in Department of Veterans Affairs cardiac catheterization laboratories. The coaching intervention comprises team-based didactic instruction with live observation at a TRA-proficient lab, followed by a visit from a cardiologist and catheterization laboratory nurse coaching team. Interview and survey data are collected from participants to test and adapt an implementation science framework known as the Promoting Action on Research Implementation in Health Services (PARIHS) framework. This study is designed to test the effectiveness of the coaching intervention on TRA implementation, inform changes to the coaching intervention itself, and test and adapt the PARIHS framework in practice. While the benefits of TRA, including increased clinical efficiency, patient comfort, and reduced patient complications, are well understood, the underlying drivers of TRA adoption and sustained practice are not. Findings from this trial can inform future research to facilitate change in the cardiac catheterization laboratory.

Leadership as a Facilitator of Evidence Implementation by Nurse Managers: A Metasynthesis.

Evidence-based practice is often not implemented in nursing for reasons relating to leadership. This article aims to cast light on the factors that facilitate nursing evidence implementation perceived by nurse managers in their practical experiences of this implementation. It is a qualitative, narrative metasynthesis of primary studies on nurse managers' leadership-related facilitation experiences, following the Joanna Briggs Institute meta-aggregative approach and the Promoting Action on Research Implementation in Health Services (PARiHS) model. Eleven primary studies were included and three general categories were identified as leadership-related factors facilitating evidence implementation: teamwork (communication between managers and staff nurses), organizational structures (strategic governance), and transformational leadership (influence on evidence application and readiness for change among leaders). Nurse managers act as facilitators of evidence-based practices by transforming contexts to motivate their staff and move toward a shared vision of change. Always providing support as managers and colleagues, sharing their experience in the clinic environment.

Action research improved general prerequisites for evidence-based practice

The present study was part of an action research project that was performed to implement a clinical pathway for patients on mechanical ventilation and simultaneously explore the implementation process in a Swedish intensive care unit. The aim of this questionnaire study was to evaluate whether an action research methodology could affect the general prerequisites for evidence-based practice (EBP). Informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, the study included registered nurses, assistant nurses and anesthesiologists in the unit at start of the project (n = 50) and at follow-up (n = 44). Data was collected with the Evaluation Before Implementation Questionnaire and the Attitudes towards Guidelines Scale.The results revealed that the general prerequisites for EBP in the setting improved. Compared to baseline measurements, the staff at follow-up conversed significantly more about the importance of the patients’ experiences, research utilization, context and facilitation, while changes with respect to clinical experiences were not significant. The attitudes towards guidelines were perceived as positive at baseline as well as at follow-up and did not significantly change.Longer professional experience was associated with a slightly lower probability of perceiving that the importance of research utilization was discussed and reflected upon, while belonging to a profession with longer education was associated with a higher probability of this perception. Compared to registered nurses and assistant nurses, the anesthesiologists perceived, to a greater extent, that the importance of clinical experience was discussed and reflected upon in the setting, while there was no significant association with the length of professional experience and/or specific professions regarding the other components.In conclusion, using action research to implement a clinical pathway methodology seems to set in motion various mechanisms that improve some but not all prerequisites that, according to the PARIHS framework, are advantageous for EBP.

An Examination of the Factors Associated With Implementation of Evidence-Based Management Practices for Improving Nurse Work Environments.

Evidence-based management practices (EBMPs) that improve nurses' work environments have been linked to improvements in patient outcomes such as patient satisfaction and mortality. Yet, the extent to which nurse managers implement these EBMP or the factors associated with their implementation is not known. Guided by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework, we examined individual, evidence, and organizational characteristics associated with nurse managers' implementation of the five EBMPs. A cross-sectional, correlational, survey design was used. Nurse managers from 10 public hospitals in New York City were recruited. Evidence and contextual variables were measured with the Organizational Readiness for Change Assessment instrument. EBMPs were measured with a modified version of the Practice Environment Scale of the Nursing Work Index. All multi-item scales were validated with confirmatory factors analysis in the studied sample. Additionally, the scales had Cronbach's alpha reliability greater than .8. A multivariate linear regression analysis with robust standard error correction was used to analyze the data and to adjust for clustering of managers in hospitals. A total of 331 nurse managers responded for a 47.4% response rate. Bachelor's degree, number of staff supervised, managers' personal experience with evidence for EBMPs, staff culture, and organizational resources were significant predictors of nurse managers' implementation of EBMPs for NWE improvement (p<.05). Staff culture was positively associated with implementation of all five EBMPs for improving nurses' work environments. Managers should prioritize nursing unit culture that encourages staff to innovate and change in order to improve care.

Structural barriers to implementing recommended tuberculosis preventive treatment in primary care clinics in rural South Africa

ABSTRACT The World Health Organization (WHO) recommends tuberculosis preventive treatment (TPT) in people with HIV (PWH), yet implementation remains poor, especially in rural communities. We examined factors influencing TPT initiation in PWH on antiretroviral therapy (ART) in rural South Africa using the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify contextual factors and facilitation strategies to successfully implement TPT. Patient and clinical factors were extracted from medical records at two primary healthcare clinics (PHCs). Among 455 TPT eligible indivdiuals, only 263 (57.8%) initiated TPT. Patient-level characteristics (older age and symptoms of fever or weight loss) were significantly associated with TPT initiation in bivariate analysis, but PHC was the only independent correlate of TPT initiation (aOR: 2.24; 95% CI: 1.49–3.38). Clinic-level factors are crucial targets for implementing TPT to reduce the burden of HIV-associated TB. Gaps in knowledge of HCW, staff shortages, and non-integrated HIV/TB services were identified barriers to TPT implementation. Evidence-based strategies for facilitating TPT implementation that might be under-prioritized include ongoing reprioritization, expanding training for primary care providers, and quality improvement strategies (organisational changes, multidisciplinary teams, and monitoring and feedback). Addressing contextual barriers through these facilitation strategies may improve future TPT implementation in this setting.

Qualitative analysis of challenges and enablers to providing age friendly hospital care in an Australian health system

BackgroundWith ageing global populations, hospitals need to adapt to ensure high quality hospital care for older inpatients. Age friendly hospitals (AFH) aim to establish systems and evidence-based practices which support high quality care for older people, but many of these practices remain poorly implemented. This study aimed to understand barriers and enablers to implementing AFH from the perspective of key stakeholders working within an Australian academic health system.MethodsIn this interpretive phenomenenological study, open-ended interviews were conducted with experienced clinicians, managers, academics and consumer representatives who had peer-recognised interest in improving care of older people in hospital. Initial coding was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Coding and charting was cross checked by three researchers, and themes validated by an expert reference group. Reporting was guided by COREQ guidelines.ResultsTwenty interviews were completed (8 clinicians, 7 academics, 4 clinical managers, 1 consumer representative). Key elements of AFH were that older people and their families are recognized and valued in care; skilled compassionate staff work in effective teams; and care models and environments support older people across the system. Valuing care of older people underpinned three other key enablers: empowering local leadership, investing in implementation and monitoring, and training and supporting a skilled workforce.ConclusionsProgress towards AFH will require collaborative action from health system managers, clinicians, consumer representatives, policy makers and academic organisations, and reframing the value of caring for older people in hospital.

Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research

BackgroundImplementation researchers recognize the influential role of organizational factors and, thus, seek to assess these factors using quantitative measurement instruments. However, researchers are hindered by instruments that measure similar constructs but rely on different nomenclature and/or definitions. The Consolidated Framework for Implementation Research (CFIR) provides a taxonomy of constructs derived from prior frameworks and empirical studies of implementation-related constructs. The CFIR includes constructs based on the original Promoting Action on Research Implementation in Health Services (PARiHS) framework which highlights the key roles of strength of evidence for a specific evidence-based intervention (EBI), favorability of organizational context for change, and capacities to facilitate implementation of the EBI. Although the CFIR is among the most frequently used implementation frameworks, it does not include quantitative measures. The Organizational Resource and Context Assessment (ORCA) is a quantitative measurement instrument that was developed based on PARiHS, assessing its three domains. Factors within these three domains are conceptually similar to constructs in the CFIR but do not match directly. The aim of this work was to map ORCA survey items to CFIR constructs to enable direct comparisons and syntheses of findings across studies using the CFIR and/or ORCA.MethodsTwo distinct, independent research teams, each used rigorous constant comparative techniques with deliberation and consensus to map individual items from the ORCA to the five domains and 39 constructs of CFIR.ResultsORCA items were mapped primarily to three of five CFIR domains: Inner Setting, Process, and Intervention Characteristics. The two research teams agreed on 88% of mappings at the higher domain level; at the lower construct level, their mappings aligned for 62.2% of the ORCA items.ConclusionsMapping results reveal that the ORCA focuses measurement prominently on Inner Setting, Process, and Intervention Characteristics. This mapping guide can help improve consistency in measurement and reporting, enabling more efficient comparison and synthesis of findings that use either the ORCA instrument or the CFIR framework. The guide helps advance implementation science utilizing mixed methods by providing CFIR users with quantitative measures for selected constructs and enables ORCA users to map their findings to CFIR constructs.

Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation.

SummaryAn informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting.PurposeAn established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility.MethodsFor this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework.ResultsOf 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success.ConclusionThe BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.

Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation

BackgroundAlthough web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated.ObjectiveThis study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed.MethodsWe used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time.ResultsA total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies—increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers.ConclusionsThis study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice.

Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.

Strategies for Implementing Group Mental Health Interventions in a VA Community Living Center

ABSTRACT Objectives: Group mental health interventions are difficult to implement into rehabilitation facilities, but no one has studied the specific barriers. This mixed-methods project systematically examined the implementation of a mental health (MH) group intervention in a VA community living center (CLC) for residents on subacute rehabilitation units, using the Promoting Action on Research Implementation in Health Services (PARIHS) implementation framework. Methods: We implemented a group MH intervention, tracking team referrals, attendance rates, and reasons for declining to participate. We conducted qualitative interviews with attendees. Results: Individual barriers to attendance included acute illness (n = 67, 20%), attitudes toward MH (n = 50; 15%), and perceived busyness (n = 19; 6%). Facility barriers included competing appointments (n = 69; 21%). Interviews demonstrated challenges to implementation, including stigma toward mental health (Theme: Challenges and Supports to Implementation). Attendees found the group relatable, and noted that both positive and negative group dynamics contributed to their experience (Themes: Content Relevance and Group Dynamics). Conclusions: The results provide insight into implementing a group MH treatment into the CLC setting, with implications for the MH care of older adults residing in CLCs. Clinical Implications: 1) Group leaders should consider matching attendees for ability levels (physical or cognitive). 2) At the facility level, leaders may take steps to address stigma toward MH by adopting approaches (e.g., music) or framing MH issues (e.g., use of language) in a way that is approachable. 3) Modifiable barriers at the individual and facility level could be addressed to encourage ease of implementation.

Knowledge implementation in health care management: a qualitative study

BackgroundThe gap between knowledge and practice is a global issue, which increases wasteful spending in healthcare. There are several models and frameworks to address this gap and try to solve the challenge. Promoting Action on Research Implementation in Health Services (PARIHS) framework highlights the interaction of three main elements: evidence, context and facilitation, to implement research into practice, successfully. This framework can use as a tool to evaluate the situation and guide the changing. This study conducted to explain the status of knowledge implementation in Iran’s healthcare management system.MethodsThis qualitative study was done by using a directive content analysis approach through conducting in-depth, structured interviews with 15 health managers based on the PARIHS framework. Guiding questions were based on the three main elements of the framework: evidence, context and facilitation. The content of the interviews entered into the Qualitative Data Analysis software (MAXQDA version 10) and, then, analyzed.ResultsThe most common source of evidence used by managers for decision-making was local information and previous experience. Evaluation more emphasized compared to other sub-elements of context, i.e. culture and leadership. In terms of facilitation, performing tasks by others was the dominant opinion.ConclusionOur results showed that managers in the healthcare system of Iran use their own and other manager’s experience and the local information for decision-making and have no ideas about facilitation.

Development, implementation, and evaluation of a novel guideline engine for pediatric patients with severe traumatic brain injury: a study protocol

BackgroundSevere traumatic brain injury (TBI) is a leading cause of death and disability for children. The Brain Trauma Foundation released evidence-based guidelines, a series of recommendations regarding care for pediatric patients with severe TBI. Clinical evidence suggests that adoption of guideline-based care improves outcomes in patients with severe TBI. However, guideline implementation has not been systematic or consistent in clinical practice. There is also a lack of information about implementation strategies that are effective given the nature of severe TBI care and the complex environment in the intensive care unit (ICU). Novel technology-based strategies may be uniquely suited to the fast-paced, transdisciplinary care delivered in the ICU, but such strategies must be carefully developed and evaluated to prevent unintended consequences within the system of care. This challenge presents a unique opportunity for intervention to more appropriately implement guideline-based care for pediatric patients with severe TBI.MethodsThis mixed-method study will develop a novel technology-based bedside guideline engine (the implementation strategy) to facilitate uptake of evidence-based guidelines (the intervention) for management of severe TBI. Group model building and systems dynamics will inform the guideline engine design, and bedside functionality will be initially assessed through patient simulation. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework, we will determine the feasibility of incorporating the guideline engine in the ICU. Study participants will include pediatric patients with severe TBI and providers at three trauma centers. Quantitative data will include measures of guideline engine acceptance and organizational readiness for change. Qualitative data will include semi-structured interviews from clinicians. We will test the feasibility of incorporating the guideline engine in “real life practice” in preparation for a future clinical trial that will assess clinical and implementation outcomes, including feasibility, acceptability, and adoption of the guideline engine.DiscussionThis study will lead to the development and feasibility testing of an adaptable strategy for implementing guideline-based care for severe TBI, a strategy that meets the needs of individual critical care environments and patients. A future study will test the adaptability and impact of the bedside guideline engine in a randomized clinical trial.

Systemwide Practice Change Program to Combat Hospital-Acquired Pressure Injuries

Considerable evidence exists on how to prevent hospital-acquired pressure injuries (HAPIs). However, processes employed to implement evidence play a significant role in influencing outcomes. One Australian health district experienced a substantial increase in HAPIs over a 5-year period (by almost 60%) that required a systemwide practice change. This article reports on the people, processes, and learnings from using the Promoting Action on Research Implementation in Health Services (PARiHS) framework taking into account the evidence, context, and facilitation to address HAPIs. Applying this approach resulted in a significant decrease in pressure injuries and positive practice change, leading to improved patient outcomes in a shorter time frame than previous strategies. Processes guided by the PARiHS enhanced the effectiveness of translating evidence into practice and positively assisted clinicians to promote optimal patient care. This approach is transferrable to other health care settings.

Challenges and Potential Solutions to Implementing Phone Coaching in Dialectical Behavior Therapy

Dialectical Behavioral Therapy (DBT) is an effective treatment for borderline personality disorder (BPD), yet many health care facilities struggle to implement one of the modes of DBT, phone coaching. The aims of this study were to present barriers and reported solutions regarding the implementation of DBT phone coaching. We conducted a sequential mixed methods national program evaluation that included a quantitative self-report survey completed by Department of Veterans Affairs (VA) facilities (N = 59) offering any of the four modes of DBT. Subsequent qualitative interviews using a semistructured interview guide informed by the Promoting Action on Research Implementation in Health Services (PARIHS) were completed with DBT providers and administrators from a subset (n = 16) of these VA sites. Four themes—the lack of tools and policies, compensation for phone coaching, clinician willingness to conduct phone coaching, and consistent program and leadership support—were identified and illustrated in a case study. This study also offered concrete recommendations for those health care organizations, managers, administrators, and clinicians who may be interested in implementing phone coaching at their health care facilities.

Implementation and development of guidelines in the emergency services in Kosovo – PARIHS framework

Abstract Background The aim of this project is to create understanding on the determinant factors enhancing adherence to treatment guidelines for the emergency medical services in Kosovo (EMSK). Focus is on barriers, and enablers while introducing the guidelines. It is aiming to create clearance and understanding of how and why the implementation outcomes are achieved. The factors influencing implementation will be mapped in three main domains. The domains are part of the determinant framework Promoting Action on Research Implementation in Health Services (PARIHS). Each of the domains is further divided into sub-constructs. Methods The process of implementing treatment guidelines into the emergency medical services in Kosovo was observed and documented by 4 researchers, using a participatory research design. The PARIHS framework that consists of three core components: evidence, context, and facilitation was applied to make clarity on what works better and why, in order to achieve the outcomes of the implemented guidelines. Results The preliminary results have shown that the three constructs have an important role in the process of implementation. The domain evidence determined the way the evidence based practice is conceived in this particular setting. The domain context concerns the organization and teamwork shaped challenges and possibilities for adherence to the guidelines. The role of an external facilitator was of specific importance. Conclusions The PARIHS framework serves in both practical and theoretical planning of an intervention. In the present project it provides clarity on planning of the process, while also offer understanding of the elements that contribute to the sustainability of the intervention. Finally the lessons from the approach can be replicated in similar context. Key messages Implementation projects can be more successful suing a framework to direct the effort. Such interventions should be premised with clarity on the evidence, the local context, and facilitation factors.

Implementation facilitation to promote emergency department-initiated buprenorphine for opioid use disorder: protocol for a hybrid type III effectiveness-implementation study (Project ED HEALTH)

BackgroundPatients with opioid use disorder (OUD) frequently present to the emergency department (ED) after overdose, or seeking treatment for general medical conditions, their addiction, withdrawal symptoms, or complications of injection drug use, such as soft tissue infections. ED-initiated buprenorphine has been shown to be effective in increasing patient engagement in treatment compared with brief intervention with a facilitated referral or referral alone. However, adoption into practice has lagged behind need. To address this implementation challenge, we are evaluating the impact of implementation facilitation (IF) on the adoption of ED-initiated buprenorphine for OUD into practice.MethodsThis protocol describes a study that is being conducted through the National Institute on Drug Abuse’s Center for the Clinical Trials Network. A hybrid type III effectiveness-implementation study design is used to evaluate the effectiveness of a standard educational dissemination strategy versus IF on implementation (primary) and effectiveness (secondary) outcomes in four urban, academic EDs. Sites start with a standard 60-min “Grand Rounds” educational intervention describing the prevalence of ED patients with OUD, the evidence for opioid agonist treatment and for innovative interventions with ED-initiated buprenorphine; followed by a 1-year baseline evaluation period. Using a modified stepped wedge design, sites are randomly assigned to the IF intervention which is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess evidence, context, and facilitation-related factors impacting the adoption of ED-initiated buprenorphine. During the 6 months of IF through the 1-year IF evaluation period, external facilitators work with local stakeholders to tailor and refine a bundle of activities to meet the site’s needs. The primary analyses compare the baseline evaluation period to the IF evaluation period (n = 120 patients with untreated OUD enrolled during each period) on (1) rates of provision of ED-initiated buprenorphine by ED providers with referral for ongoing medication (implementation outcome) and (2) rates of patient engagement in addiction treatment on the 30th day after the ED visit (effectiveness outcome). Finally, we will perform a cost-effectiveness analysis (CEA) to determine if the effectiveness benefits are worth the additional costs.DiscussionResults will generate novel information regarding the impact of IF as a strategy to promote ED-initiated buprenorphine.Trial registrationClinicalTrials.gov NCT03023930 first posted 1/10/2017, https://clinicaltrials.gov/ct2/show/NCT03023930?term=0069&rank=1

Understanding Decision Making and Barriers to Fertility Preservation in Young Women With Cancer [21S

INTRODUCTION: Many women recognize a cancer diagnosis as a time to evaluate their desire for future fertility. While financial barriers to fertility preservation are well documented, other barriers are not often addressed. We sought to explore patients' experiences when considering fertility preservation options after cancer diagnosis and their perceived barriers to pursing those options. METHODS: We conducted twenty semi-structured interviews with female oncology patients ages 18-45 years who were stable on treatment or had completed therapy within the last 24 months at an urban northeast medical center. We analyzed data using direct content analysis using the Promoting Action on Research Implementation in Health Services (PARiHS) framework. We continued participant recruitment until we reached thematic saturation. RESULTS: Patients struggle to process complex, future-based decision-making when coping with a cancer diagnosis. Three subthemes emerged: 1) patients' personal biases and fears, rather than data, about pregnancy post-chemotherapy contribute notably to decision making; 2) patients perceive biases from their providers against fertility preservation; and 3) fertility desires are fluid, thus patients may regret not exploring fertility preservation options. CONCLUSION: Decision-making regarding fertility preservation in women with a cancer diagnosis is complex. Within the current model of care, patients may not be able to fully explore their fertility preservation options, particularly in the acute diagnosis setting. A shared-decision making approach, with their own obstetrician–gynecologist, may facilitate difficult decision-making. The general obstetrician-gynecologist may play a crucial role in helping patients to navigate their desires to engage in fertility preservation options after the specialist consult.

Advancing complexity science in healthcare research: the logic of logic models

BackgroundLogic models are commonly used in evaluations to represent the causal processes through which interventions produce outcomes, yet significant debate is currently taking place over whether they can describe complex interventions which adapt to context. This paper assesses the logic models used in healthcare research from a complexity perspective. A typology of existing logic models is proposed, as well as a formal methodology for deriving more flexible and dynamic logic models.AnalysisVarious logic model types were tested as part of an evaluation of a complex Patient Experience Toolkit (PET) intervention, developed and implemented through action research across six hospital wards/departments in the English NHS. Three dominant types of logic model were identified, each with certain strengths but ultimately unable to accurately capture the dynamics of PET. Hence, a fourth logic model type was developed to express how success hinges on the adaption of PET to its delivery settings. Aspects of the Promoting Action on Research Implementation in Health Services (PARIHS) model were incorporated into a traditional logic model structure to create a dynamic “type 4” logic model that can accommodate complex interventions taking on a different form in different settings.ConclusionLogic models can be used to model complex interventions that adapt to context but more flexible and dynamic models are required. An implication of this is that how logic models are used in healthcare research may have to change. Using logic models to forge consensus among stakeholders and/or provide precise guidance across different settings will be inappropriate in the case of complex interventions that adapt to context. Instead, logic models for complex interventions may be targeted at facilitators to enable them to prospectively assess the settings they will be working in and to develop context-sensitive facilitation strategies. Researchers should be clear as to why they are using a logic model and experiment with different models to ensure they have the correct type.