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5th UK Implementation Science Research Conference

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Oral Presentations

A standardised method for the economic evaluation of implementation programmes: evaluating national programmes to increase the uptake of magnesium sulphate in pre-term births

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PRESENter

Carlos Sillero-Rejon
Carlos-pic1

authors

Carlos Sillero-Rejon, William Hollingworth, Hugh McLeod, Brent C. Opmeer, Karen Luyt

Biography

Carlos is now focused on contributing to a broad range of applied health research projects at NIHR Applied Research Collaboration (ARC) West in collaborations between academia, the NHS and other partners. A recent focus of his work is related to bringing evidence into practice and behaviour change interventions. He is also part of the Health Economics Bristol (HEB) at Bristol Medical School.

Before joining ARC, Carlos completed my PhD (finished in 2020) in behavioural economics and experimental psychology. Particularly, he studied the impact of labelling interventions in tobacco and alcohol products.

He use a wide range of methodologies including experimental techniques, cost-effectiveness analysis, decision analysis models or qualitative analyses in multidisciplinary fields. Always orientated in promoting common good: consumerism, public health interventions, harm reduction, mental health, and behaviour change in general.

Carlos is also interested in public and policy engagement and consider it as an important aspect of his work. He also have some experience in teaching and supervising students. He teaches health economics on the Master course in Public Health and NIHR ARC West training course on Health Economics.

background

Background: methods for the economic evaluation of implementation initiatives to increase the uptake of cost-effective healthcare interventions are not standardised. Value of implementation and policy cost-effectiveness are two proposed approaches. This research aims to demonstrate that these are mathematically equivalent and propose a standardised approach. To illustrate this, we evaluated two implementation programmes to increase magnesium sulphate uptake in preterm labour to reduce the risk of cerebral palsy: i) the National PReCePT Programme (NPP) which provided support and funded clinical time in maternity units in England, and ii) the PReCePT enhanced support model (ESP), which was nested within NPP in a cluster RCT.

MEthod

Methods: after summarising value of implementation and policy cost-effectiveness approaches, we show that they are mathematically equivalent, and propose a standardised stepwise method. We apply this method to the NPP (versus pre-existing trends) and the ESP (versus the NPP) calculating incremental cost-effectiveness ratios, net monetary benefits, and probabilities of being cost-effective.

results

Results: estimating the cost-effectiveness of implementation programmes depends on the change in the healthcare technology uptake, cost of the implementation, size of the eligible population, and the cost-effectiveness of the healthcare technology. With our standardised stepwise analysis approach, the NPP cost £6,044 to implement per maternity unit and generated a societal lifetime net monetary benefit of £30,247 per unit over 12 months, at a willingness-to-pay threshold of £20,000; the probability of being cost-effective was 98%. In contrast, the ESP cost £16,869 to implement per unit and generated a net monetary benefit of -£28,682 per maternity unit in comparison to the NPP; the probability of being cost-effective was 22%.

Conclusion

Conclusions: our standardised stepwise method enables the economic evaluation of implementation initiatives and is useful for implementation research. In this case, the NPP was highly cost-effective, but the addition of enhanced support was unlikely to be cost-effective.

Application of Normalisation Process Theory in the national scaling of early intervention for eating disorders

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PRESENter

Katie Richards
KRHeadshot

authors

Katie L. Richards, Karina L. Allen, & Ulrike Schmidt

Biography

Katie Richards is a Research Associate working in King’s Improvement Science (KIS) at the Centre for Implementation Science, King’s College London. Her role involves conducting mixed-methods improvement and implementation research projects across King’s Health Partners. Before starting the Research Associate post, she completed her PhD at King’s College London, where she evaluated the national implementation and outcomes of an early intervention service for eating disorders in the UK.

background

Theories provide evidence-based and flexible tools to evaluate implementation processes. The Normalisation Process Theory (NPT) is a widely used implementation theory with demonstrated utility in supporting process evaluations. This study evaluated the role of NPT mechanisms in the national implementation, embedding, and integration of an early intervention services for eating disorders.

MEthod

A mixed method evaluation was conducted. Twenty-one clinicians completed semi-structured interviews, and 211 clinicians completed longitudinal NPT questionnaires (NoMAD) administered before and after training and at a 3-month follow-up. For the qualitative data, the NPT was applied to inductively derived themes/subthemes to further evaluate underlying implementation mechanisms. The questionnaire data were analysed using multi-level growth models.

results

The inductive thematic analysis yielded six themes and 15 subthemes outlining barriers and facilitators to implementation at the wider system, service, implementation strategy, intervention, clinician, and patient levels. The early intervention service was largely normalising in teams with high levels of sense-making, engagement, collection action, and appraisal work taking place. These NPT mechanisms were more evident for some subthemes (e.g., compatibility and integration) than others (e.g., patient complexity and comorbidities). Insufficient capacity was the main factor inhibiting the normalisation in services. The quantitative data paralleled the qualitative findings. Specifically, NPT mechanisms were high at the outset, especially ‘buy-in’ and engagement. The training led to significant improvements in the NPT subscales, which continued to improve or remained approximately the same at the 3-month follow-up. The exception to this were the items related to sufficient training and resources, which initial improved post-training, but reduced at the 3-month follow-up.

Conclusion

The NPT characterised key mechanisms that were shaped by and interacted with features of the early intervention service, implementation strategy, and context to facilitate or hinder implementation. However, not all aspects of the implementation were directly captured by the theory.

Barriers and facilitators to achieving co-production in care home settings: findings from a scoping review

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PRESENter

Fran Hallam
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authors

Fran Hallam, Katie Robinson, Meri Westlake, Pip Logan, Stephen Timmons

Biography

Fran Hallam is a Clinical Researcher at Nottingham University Hospitals NHS Trust and a PhD student at the Centre for Rehabilitation and Ageing at the University of Nottingham. She holds a Masters degree in Public Health. She is a registered physiotherapist with previous experience of working in care home and falls service settings.

Fran’s PhD topic is co-production of falls management approaches in care homes. Her PhD forms part of a NIHR funded research project which aims to develop a novel model for the implementation of falls management in care home settings.

background

Co-production involves the public, practitioners and academics working together as equals throughout all research stages [1]. Co-production may help to develop pragmatic, context-specific approaches to implementation which are acceptable to those living and working in care homes [2]. This scoping review aimed to map co-production approaches used in care homes for older adults in previous research, and to identify barriers and facilitators to achieving co-production in this context.

MEthod

The review was conducted following the Joanna Briggs Institute methodology for scoping reviews [3]. Seven databases were searched for published studies using co-production approaches in a care home setting. Studies were independently screened against eligibility criteria by two reviewers and citation searching was completed. Barriers and facilitators to co-production were synthesised using a deductive thematic analysis approach guided by the NIHR INVOLVE principles of co-production [1].

results

19 studies were included. The focus and application of co-production approaches varied across the studies. 11 studies reported barriers and 13 reported facilitators affecting the co-production process. Barriers and facilitators to building relationships and achieving inclusive, equitable and reciprocal co-production were identified in alignment with the five NIHR INVOLVE principles (Table 1). Practical considerations were also identified as potential barriers and facilitators.

Conclusion

The review has identified key factors which may influence authentic co-production in care home settings. The barriers and facilitators identified will inform the design of further research which aims to co-produce an implementation model for falls management in care homes.

Challenges to Implementing Person-Centred Outcome Measures into Routine Paediatric Palliative Care

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PRESENter

Hannah M Scott
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authors

Hannah M Scott, Lucy Coombes, Debbie Braybrook, Daney Harðardóttir, Anna Roach, Katherine Bristowe, Clare Ellis-Smith, Richard Harding, on behalf of C-POS

Biography

Hannah (She/They) has a Bachelor of Arts in Children, Young People and Families from York St. John University and a Master of Science in Social Policy and Social Research from University College London.
She joined the Cicely Saunders Institute at King’s College London in 2020 as a mixed methods research assistant working on the Children’s Palliative care Outcomes Scale (C-POS) study. Shortly after she won a competitive ARC PhD studentship and began her PhD studies at King’s, working on implementing of C-POS measures into routine practice. She is also the deputy coordinator for the European Association for Palliative Care’s Task Force for improving palliative and end of life care for LGBT+ people

background

To successfully implement a newly developed measure into clinical practice, the challenges to implementation must be understood. Previous research has focused on disease-specific or generic Quality of Life measures in paediatric healthcare, or the use of outcome measures in adult palliative care. Evidence identifying the perspectives of all key stakeholder groups is needed to ensure successful implementation of new person-centred outcome measures (PCOMs) in the paediatric palliative care context.

MEthod

Semi-structured interviews with purposively sampled key stakeholders. Children with life-limiting or life-threatening conditions (LLLTC), parents/carers and siblings of children with LLLTC, and health and social care professionals (HSCPs) caring for children with LLLTC were recruited from 9 UK sites. Commissioners of UK paediatric palliative care services were recruited via a non-governmental organisation or direct recommendations. Verbatim transcripts were analysed using a Framework approach analysis and inductive coding in NVivo.

results

103 interviews were conducted with 106 participants (26 children, 40 parents/carers, 13 siblings, 15 HSCPs, and 12 commissioners). Potential challenges identified by HSCP and commissioners included: (1) gatekeeping by family members and (2) added workload for already stretched services. Potential challenges identified by children included: (1) trusting who administered the measure and (2) privacy concerns around who could access the results. Family members also identified potential challenges relating to (1) added workload for HSCP and (2) privacy concerns around who could access the results.

Conclusion

Whilst some challenges were identified as concerns across multiple stakeholder groups, other challenges identified were unique to specific stakeholder groups. Understanding these different and over lapping perspectives of the perceived challenges is essential for the development of concomitant strategies for implementation of a new PCOM into paediatric healthcare practice. Which in turn helps to support uptake of a PCOM into routine practice.

Developing an initial programme theory of prehospital feedback in an ambulance service setting: A mixed-methods study

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PRESENter

Caitlin Wilson
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authors

Caitlin Wilson, Dr Gillian Janes, Professor Rebecca Lawton, Dr Jonathan Benn

Biography

Caitlin Wilson (@999_Caitlin) is a final year PhD student at the University of Leeds, United Kingdom, funded by the National Institute for Health Research Yorkshire and Humber Patient Safety Translational Research Centre, and supervised by Dr Jonathan Benn, Professor Rebecca Lawton and Dr Gillian Janes. Caitlin is also a paramedic for North West Ambulance Service NHS Trust and an Associate Editor for the British Paramedic Journal.
Caitlin’s PhD explores how enhancing prehospital feedback can enrich emergency ambulance staff wellbeing, paramedic decision-making and prehospital patient safety. As part of her PhD, Caitlin has conducted several research studies including a systematic review, a qualitative interview study and a mixed-methods diary study. At this conference, Caitlin is presenting on the development of an initial programme theory of prehospital feedback as part of an ongoing mixed-methods study combining a realist evaluation framework with an explanatory case study design.

background

Evidence exists for the effectiveness of feedback in changing professional behaviour and improving clinical performance across a range of healthcare settings, but this has not yet been explored within the prehospital context (Ivers et al., 2012). The aim of this study was to understand how UK ambulance services are meeting the challenge of providing feedback and generate an initial explanatory programme theory to capture the implicit mechanisms by which prehospital feedback results in desirable outcomes.

MEthod

This mixed methods study combines a realist evaluation framework with an explanatory case study design. The study consisted of a national cross-sectional survey to identify active and historic feedback initiatives in UK ambulance services, followed by 4 in-depth case studies of these initiatives. Case studies were purposively selected from survey responses using a sampling framework stratified by feedback type and context, and each involved 4-5 semi-structured qualitative interviews and documentary analysis.
An initial programme theory was developed using the survey data and findings from our previously conducted systematic review and exploratory interview study. It was informed by existing theories on audit and feedback, behaviour change and implementation science: Clinical Performance Feedback Intervention Theory (Brown et al., 2019), Theoretical Domains Framework (Michie et al., 2005) and Implementation Outcomes Evaluation Framework (Proctor et al., 2011)).

results

Fitting the descriptive survey data of prehospital feedback initiatives to the CMO framework gave rise to an initial programme theory for prehospital feedback, which is depicted visually in a logic model.

Conclusion

Our initial programme theory will be further refined during the ongoing case study phase of this study.

Development of implementation strategies to overcome barriers when implementing a combined lifestyle intervention for community-dwelling older people in community-care settings

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PRESENter

Patricia van der Laag
photo-Patricia

authors

Patricia J van der Laag*, Berber G Dorhout, Aaron A Heeren, Di-Janne JA Barten Cindy Veenhof, Lisette Schoonhoven

Biography

Patricia is a PhD student at University Medical Center Utrecht in the Netherlands. Her project is focusing on the implementation of a combined lifestyle intervention, ProMuscle, for community dwelling older adults.
With more than 10 years’ experience as a physical therapist in geriatric care, a need for improving health care especially for the older adults grew more and more. Therefore, Patricia started the master Clinical Heath Sciences at the University of Utrecht and obtained her master’s degree in 2020.
Research interest include implementation, prevention, and health care for older adults.

background

ProMuscle is a combined lifestyle intervention that has shown to be effective in improving muscle mass, muscle strength, and physical functioning in community-dwelling older adults. Potentially, it could facilitate older people in maintaining their functional independence.
To increase the likelihood of successful implementation of ProMuscle, this study aims to develop appropriate implementation strategies targeting previously identified barriers to implement ProMuscle in community-care.

MEthod

A theory-informed approach was adopted to develop appropriate implementation strategies, consisting of four subsequent steps. First, previously identified barriers for implementation were categorized into the constructs of the Consolidated Framework for Implementation Research (CFIR)[1], including the underlying theoretical constructs. Second, the CFIR-ERIC matching Tool linked barriers to implementation strategies. Behavioral change strategies were added from literature. Third, evidence for implementation strategies was sought in literature. Fourth, in co-creation with involved healthcare professionals and implementation experts, implementation strategies were operationalized to practical implementation activities following the guidance of Proctor. Lastly, an implementation plan that can be tailored to individuals’ context was developed, prioritizing implementation activities over time.

results

A total of 654 barriers were categorized to the CFIR framework. The majority of barriers were related to the CFIR domain outer setting. Subsequently, the identified barriers were linked to 37 unique strategies. As many strategies affected multiple barriers, strategies were assigned in eight overarching themes: assessing the context, network internally, network externally, costs, education, process, champions, content of the intervention, and behavioral change of the end-users.
Co-creation sessions with professionals and implementation-experts resulted in tangible implementation actions, processed into an online implementation toolbox that supports healthcare professionals chronologically during the implementation process.

Conclusion

The theory-informed approach in combination with co-creation led to the development of practical multicomponent implementation strategies to implement ProMuscle. Next step is to evaluate the implementation strategies including the implementation toolbox regarding the implementation of ProMuscle in community-care.

Evaluating Implementation Fidelity to a nurse-led model “INTERCARE”: A Mixed-Methods Study

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PRESENter

Raphaëlle Guerbaai
Moi_pro

authors

Raphaëlle A. Guerbaai; Sabina DeGeest; Michael Simon; Lori L. Popejoy; Nathalie I. H. Wellens4; Kris Denhaerynck; Franziska Zúñiga.

Biography

Raphaëlle-Ashley Guerbaai graduated with a BSc (Hons) Nursing Degree from the University of Liverpool, UK in 2010 and decided to continue her university education with a Master of Science in Infectious Disease Control (specializing in Epidemiology and Public Health). She received her MSc in spring of 2012 from the London School of Hygiene and Tropical Medicine after working for 6 months on the epidemiology of septicaemia for the Ministry of Health in Tanzania, East Africa. Subsequently, Raphaëlle worked as a specialist nurse in cardiology intensive care at the University Hospital of Grenoble, France.
Raphaëlle completed her Ph.D. in April 2022 working on the INTERCARE project (Nursing Models for Care in Swiss Nursing Homes: Improving INTERprofessional CARE for Better Residential Outcomes), specializing in implementation science and is part of the Patient Safety and Quality of Care Research Group. Since 2022 she is working as a postdoctoral researcher at the Institute of Nursing Science and has recently been awarded a postdoctoral mobility grant.

background

Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Little is known about how it acts as a moderator between an intervention and its intended outcome(s) and what elements affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity in INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) with the aim of reducing unplanned hospital transfers. INTERCARE has six core elements that were introduced, among them advance care planning and tools to support inter- and intraprofessional communication.

MEthod

A mixed-methods design was used, guided by the Conceptual Framework for Implementation Fidelity. Fidelity to INTERCARE’s core components was measured with 44 self-developed items at 4 time points (baseline, 6, 12 months post intervention, 9 months post-intervention end); fidelity scores were calculated for each component and overall. Notes from NH meetings were used to identify moderators affecting the fidelity trajectory over time. Generalized linear mixed models were computed to analyze the quantitative data. Deductive thematic analysis was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation.

results

A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI=0.43-0.99), p=0.047). Higher fidelity score to advance care planning was associated with lower unplanned transfers (OR= 0.24 (CI 0.13-0.44), p= < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR= 1.69 (CI 1.30-2.19), p= < 0.003).

Conclusion

High implementation fidelity to INTERCARE was necessary to achieve a reduction in unplanned transfers. In-house physicians with a collaborative approach and staff’s perceived need for nurses working in extended roles, were important factors supporting reaching high fidelity. Further research is needed to understand what supports the effective implementation of single elements.

Evaluation of the scale up of remote monitoring in rheumatology outpatients across three NHS trusts in London, UK

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PRESENter

Helen Sheldon
WIN_20220704_12_13_34_Pro

authors

Helen Sheldon, Kathryn Watson, Rachel Olive, Elena Pallari, Camille Aznar, Nikita Arumalla, Olga Boiko, Melanie Martin, Len Demetriou, Emily Jane Smith, Emma-Jayne Adams, Mary-Ann Palmer, Nick Sevdalis, Andrew Walker, Toby Garrood

Biography

Helen Sheldon joined the Health Innovation Network in 2018, working on a large mixed methods process and impact evaluation of the roll out of ESCAPE-pain in the community and leisure sectors. Since then, she has led evaluations of Remote Monitoring in Rheumatoid Arthritis, Micro-volunteering and a Whole Schools Approach to children and young people’s emotional wellbeing. She has also supported companies on the Digital Health.London Accelerator and Launchpad Programmes develop their evidence base and been part of a multi-agency collaboration to extend the work of the DH.L Evidence Generator to create a national digital evidence hub.

Helen has over twenty years’ experience of evaluating initiatives in settings across health and social care, using a broad range of techniques. She has a particular expertise in qualitative methods and in stakeholder engagement, and specialist knowledge of quality assurance and information security in managing research and evaluation projects.

background

Modern treat-to-target approaches to rheumatoid arthritis (RA) involve frequently monitoring disease activity via patient reported outcome measures (PROMs). Remote monitoring (RM) of PROMs can support care through more timely intervention and fewer unnecessary appointments. This study aimed to evaluate the feasibility of scaled implementation of a RM system for people with RA at three NHS trusts in London, UK.

MEthod

This was a prospective mixed-methods evaluation with service user involvement throughout. We report on the patient survey and semi-structured interviews with staff and patients exploring perspectives on the RM system. Interview schedule design and analysis for clinician and patient were informed by the EPIS1 and COM-B2 frameworks, respectively.

results

Sixteen staff were interviewed. The system was implemented in two stages: an initial pilot at one trust then roll out to two other trusts. The four EPIS phases (Exploration, Preparation, Implementation and Sustainment) were evident in the pilot trust, but exploration and preparation were less evident at the other trusts. Adoption beyond the pilot trust was low with staff concerned about integration into clinical practice and systems.

Twenty-two patients were interviewed and 163 responded to the survey. Patients were overwhelmingly positive about the RM system. It was easy to use and required no skills beyond those used in their daily life. Patients were motivated to adopt the RM system by an interlinked set of beliefs regarding its use. A key motivator was increased responsiveness and ease of contact with the clinical service.

Conclusion

There was a contrast between the views of patients and staff outside of the pilot trust about RM. The lower adoption and associated concerns of staff about RM beyond the pilot site may be due to insufficient involvement at the Exploration and Preparation phases. The EPIS provides a useful framework for understanding challenges and approaches to scaling effectively.

Evidence gap map on contextual analysis in implementation science

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PRESENter

Juliane Mielke
Mielke-Juliane_2

authors

Juliane Mielke, Thekla Brunkert, Franziska Zúñiga, Michael Simon, Leah L. Zullig, Sabina De Geest

Biography

Juliane Mielke is a Postdoctoral Research Fellow at the Institute of Nursing Science at the University of Basel, Switzerland. She has a background in nursing and worked for several years in acute care settings in Germany and Switzerland. Juliane completed her PhD in 2022 which included the development of a methodology for studying context in implementation science. Her current research focuses on the combination of implementation science, systems science methods and routine data.

background

Understanding context is essential for successful and sustainable intervention implementation. However, a lack of standardised methodological approaches for contextual analysis limits the assessment and leads to inconsistent reporting of context. We systematically reviewed intervention implementation studies to map and evaluate current methodological approaches to contextual analysis.

MEthod

Applying a stepwise evidence gap map (EGM) approach, we empirically developed a search strategy to identify intervention implementation studies in PubMed (2015-2020). From a random sample (20%) of articles per year we assessed those in detail that reported on contextual analysis. Data extraction, analysis and evaluation was guided by the Basel Approach for CONtextual ANAlysis (a six-step guidance for contextual analysis) and the Context and Implementation of Complex Interventions (CICI) framework. We created colour coded tables and visual maps to provide an overview on all relevant findings.

results

We identified 15,286 intervention implementation studies and protocols, of which 3017 were screened for inclusion. Finally, 110 studies were included, with 24 (22%) reporting on contextual analysis.
Only one study used a framework explicitly guiding contextual analysis. Twenty-two studies focused on the meso-level (i.e., organisational characteristics) with socio-cultural aspects most frequently being studied. Commonly applied methods included surveys (n=15) and individual interviews (n=13), with ten studies reporting a mixed-methods analysis. In 18 studies, contextual information was used to inform subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies); nine studies assessed influences of context on implementation and effectiveness outcomes.

Conclusion

This study provides an overview on current methodological approaches to contextual analysis while highlighting their gaps. The huge heterogeneity identified turns contextual analyses into “black boxes”. We strongly recommend taking concerted actions to further develop and test robust methodologies for contextual analysis and consistent reporting (e.g., following BANANA), to increase the quality and consistency of implementation science research.

Experiences and perceptions of evidence use among senior health service stakeholders: A qualitative study

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PRESENter

Susan Calnan
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authors

Dr Susan Calnan, Dr Sheena McHugh

Biography

Dr Susan Calnan is a post-doctoral researcher at the School of Public Health, University College Cork. Her research interests include implementation science and knowledge translation. Dr Calnan completed her PhD in 2019, focusing on the evaluation of an alcohol prevention programme. Since then, she has been involved in a number of research projects focusing on the implementation of health services and/or evidence. Prior to this, she worked for 10 years in research publishing for organisations including the European Foundation for the Improvement of Living and Working Conditions. She also holds a Professional Certificate in Knowledge Translation.

background

The importance of using robust evidence to inform policy and decision-making in health is widely acknowledged. Nevertheless, the evidence-to-policy and practice gap continues to persist. The aim of this study was to examine senior health service stakeholders’ experiences and perceptions of evidence us; identify barriers to and facilitators of research use; and identify recommendations to support research use among health service stakeholders.

MEthod

A qualitative study was conducted using semi-structured one-to-one interviews with a sample of senior health service stakeholders in Ireland. Interviews were conducted in late August 2021 to January 2022. Purposive sampling was used, and inclusion criteria were national-level senior management involved in making decisions regarding strategy, planning, development and delivery of health services. Interviews were analysed using thematic analysis.

results

A total of 17 interviews were conducted, representing a response rate of approximately 38%. Participants reported using a range and mix of evidence types to inform their work and decision-making, and they had a strong appreciation of the importance of research. Barriers, facilitators and recommended supports were further categorised according to individual, organisational, research itself, social, economic and political factors. Key barriers to research use ranged from individual barriers such as lack of time and other stakeholders’ lack of understanding or interest in research to organisational barriers such as access and the culture of research. Key facilitators included social factors such as links with external organisations, particularly universities, and organisational factors such as the internal library service.

Conclusion

The study points to a dynamic evidence use ecosystem among those interviewed. Notwithstanding these positive findings, a range of barriers to research use were identified at multiple levels. The study highlights the need for a more proactive and strategic approach to support evidence use in health service organisations. These should include strategies targeted at tangible elements such as available resources, but also less tangible elements such as the climate or culture of research in the organisation.

Implementation strategies to increase smoking cessation treatment provision in primary care: a systematic review of observational studies

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PRESENter

Bernadett Tildy
Bernadett-Tildy-presenter-photo

authors

Bernadett E Tildy, Ann McNeill Parvati R Perman-Howe, Leonie S Brose

Biography

Bernadett is a 2nd year PhD student within the Nicotine Research Group in the Addictions Department at King’s College London. She is supervised by Dr Leonie Brose and Professor Ann McNeill.

PhD thesis provisional title: Improving the provision and uptake of smoking cessation treatment in the United Kingdom.
Overarching aim of her PhD is to investigate how smoking cessation treatment provision in the UK could be improved, and to explore how prescription e-cigarettes may help to do this, to further reduce the prevalence of smoking and meet the smoke-free 2030 target (adult smoking prevalence to be 5% or less in England).

Bernadett’s PhD funding: 1+3 (Masters + PhD) Economic and Social Research Council (ESRC) London Interdisciplinary Social Science Doctoral Training Partnership (LISS DTP).

Qualifications:
• Medicine, Health and Public Policy MSc (King’s College London) 2019-2020
• Biomedical Science BSc (Imperial College London) 2012-2015

background

Controlled trials have found some evidence for the efficacy of interventions aiming to increase the provision of smoking cessation treatment in primary care settings [1], but we need ‘real-world’ evidence, where implementation strategies [2] are implemented without researcher input. Aim: To identify ‘real-world’ implementation, effectiveness and cost-effectiveness of implementation strategies aiming to increase smoking cessation treatment provision in primary care, and any perceived facilitators and barriers for effectiveness.

MEthod

Seven databases, and three grey literature sources were searched from inception to April 2021. Studies were included if they evaluated implementation on a national or state-wide scale, contained practitioner performance and patient smoking outcome measures. Studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was conducted using the ERIC compilation [3,4] and CFIR [5].

results

Of 49 included papers, half were of moderate/low risk of bias. The implementation strategies identified involved utilising financial strategies, changing infrastructure, training and educating stakeholders, and engaging consumers. The first three strategies increased the provision of cessation advice in primary care but no intervention had high-quality evidence of impact on patient smoking cessation. No studies assessed cost-effectiveness. External policies/incentives (wider tobacco control measures and funding for public health and cessation clinics) were key facilitators. Time and financial constraints, lack of free cessation medications and follow-up, deprioritisation and unclear targets in primary care, lack of knowledge of healthcare professionals, and unclear messaging to patients about cessation were key barriers.

Conclusion

Some implementation strategies increased the rate of delivery of cessation advice in primary care, but there was no high-quality evidence showing an increase in quit attempts or smoking cessation. Barriers to effectiveness identified in this review should be reduced. More pragmatic approaches are recommended, such as ‘hybrid effectiveness-implementation designs’, and ‘Multiphase Optimization Strategy’ (MOST) [6].

Trial Registration PROSPERO: CRD42021246683

References:
1. Lindson N, Pritchard G, Hong B, Fanshawe TR, Pipe A, Papadakis S. Strategies to improve smoking cessation rates in primary care. Cochrane Database of Systematic Reviews. 2021 Sep 6;2021(9).
2. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implementation Science. 2013;8(1):139.
3. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science. 2015;10(1):109.
4. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015;10(1):21.
5. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug;4:50.
6. Collins LM, Baker TB, Mermelstein RJ, Piper ME, Jorenby DE, Smith SS, et al. The multiphase optimization strategy for engineering effective tobacco use interventions. Ann Behav Med. 2011 Apr;41(2):208–26.

Is Implementation Research Out of Step with Implementation Practice? Pathways to Effective Implementation Support Over the Last Decade

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PRESENter

Dr. Allison Metz
Allison-Metz-Photo

authors

Allison Metz, Todd Jensen, Amanda Farley, Annette Boaz

Biography

Allison Metz, Ph.D., is a developmental psychologist with expertise in child development and family systems and a commitment to improving child and family outcomes and advancing equity. Allison specializes in the implementation of evidence to achieve social impact for children and families in a range of human service and education areas, with an emphasis on child welfare and early childhood service contexts. Allison is Professor of the Practice and Director of Implementation Practice at the School of Social Work, Faculty Fellow at the FPG Child Development Institute, and Adjunct Professor at the School of Global Public Health at The University of North Carolina-Chapel Hill. She is also an Adjunct Professor at the School of Medicine at Trinity College Dublin. Allison previously served as Director of the National Implementation Research Network and Lead of the Implementation Science Division at the FPG Child Development Institute where she also served as a Senior Research Scientist for 13 years. Allison’s research interests include the role of trust, power and relationships in evidence use, competencies for supporting implementation, and co-creation strategies to support sustainable change. She is particularly interested in the development of a workforce for supporting implementation in public systems. Allison is co-chair of the Institute on Implementation Practice and founding director of the Collaborative for Implementation Practice at UNC-Chapel Hill School of Social Work. She is the co-editor of the widely read volume Applying Implementation Science in Early Childhood Programs and Systems.

background

Implementation support has become a frequently used approach to strengthen organizational efforts to sustainably use evidence. In utilizing implementation support, agencies and funders collaborate with implementation support practitioners (ISPs) whose explicit role it is to support the implementation of evidence-informed practices (1, 2, 3). The goals of this study were to understand what experienced ISPs have learned about supporting evidence use in service systems, and how their approach to providing implementation support has shifted over time as a result of this learning.

MEthod

A purposive sample of 17 experienced ISPs participated in in-depth interviews. A semi-structured interview guide was used to ascertain participants’ perceptions about various aspects of their work providing implementation support. Data were analyzed using a narrative analysis approach, focusing on broad elements that highlighted the trajectory of respondents’ professional journey in the context of providing implementation support. A team engaged in data coding and analysis in an effort to triangulate observations and maintain consensus with respect to emerging findings.

results

Respondents foregrounded the development of five main components to their approach in supporting evidence use: (a) supporting participatory learning; (b) engaging in co-creation; (c) building trusting relationships; (d) understanding context and community perspectives; and (e) supporting communication, coordination and collaboration. Interviewees described a necessary evolution in their approach to supporting evidence use. Three main shifts in implementation support practice were observed: (a) didactic to participatory approaches, (b) expert-driven to co-creation approaches, and (c) framework-based to relationship-focused approaches

Conclusion

Respondents highlighted the need to move away from top-down approaches towards a model of multi-level support focused on co-creation, peer learning, and collaborative work. At the heart of this work is development of trusting relationships. All interviewees reported that high quality relationships between ISPs and stakeholders was the most critical factor for achieving implementation results.

The DARE Framework – To deliver higher value health care

O30

PRESENter

Tracey Brighton
Photo-2-for-Bios

authors

Dr Jack Bell, Tracey Brighton, Dr Tamlyn Rautenberg and Nina Meloncelli

Biography

Tracey Brighton is an Allied Health Professional with over 22 years of experience working in the healthcare industry as both a clinician and a healthcare leader. Possessing a clinical background in Physiotherapy, she has worked in both the public and private sectors and has held leadership positions in the public health system for the past 12 years. Tracey has extensive experience in strategic leadership and planning, workforce redesign and development, project and change management and service development.

To complement her a Bachelor of Physiotherapy and a Graduate Diploma in Health Management, Tracey has recently completed a Diploma of Professional Coaching.

background

Discover disinvestments, Adapt or abandon, Reinvest or recoup, and Evaluate and embed; introducing the DARE Framework to deliver higher value healthcare
More than 80 implementation theories, models and frameworks support implementation of health service innovations and translating knowledge to practice; growing attention is directed towards deimplementation approaches. However, a pragmatic, integrated model or framework that supports pragmatic deimplementation to reinvest approaches remains lacking.
This initiative aimed to co-design a framework and toolkit to support de-implementation to reinvest healthcare improvements

MEthod

The knowledge-to-action framework underpinned development of the DARE Framework and toolkit for feasibility testing in a convenience sample of allied health services in a single metropolitan hospital.

results

An initial conceptual framework synthesised concepts from underlying theories (n=3), process models(n=5), determinant(n=5) and evaluation frameworks (n=3) in August 2021. Iterative co-design with stakeholders between August 2021 and October 2021 applied data from twenty-four nominal group technique workshops, and 3 semi-structured small group interviews. Findings were triangulated using informal focus groups, interviews and meetings to co-engage stakeholders in the iterative development, implementation, and refinement of the model and draft toolkit. Full consensus for facilitated rapid action cycle implementation and pragmatic feasibility testing of the draft model across allied health services for a 700+ bed hospital was then achieved in November 2021 in response to COVID driven budgetary and care needs. At time of abstract preparation, RE-AIM evaluation demonstrates ongoing iterative adaptation of the model and toolkit, willingness for update and spread to medical and nursing professions, adoption, implementation and embedment of ranked deimplementation and reinvestment opportunities across all core allied health services in the test site. Limited effectiveness testing to date across process measures and quadruple aim healthcare outcomes appears strongly favourable; detailed findings will presented at conference as a qualitative case series.

Conclusion

Early data supports consideration of the DARE Framework as a useful approach to support rapid cycle, deimplement to reinvest approaches to facilitate values-based health care.

The Role of Trusting Relationships in Supporting Implementation

O43

PRESENter

Dr. Allison Metz
Allison-Metz-Photo1

authors

Allison Metz, Todd Jensen, Amanda Farley, Annette Boaz

Biography

Allison Metz, Ph.D., is a developmental psychologist with expertise in child development and family systems and a commitment to improving child and family outcomes and advancing equity. Allison specializes in the implementation of evidence to achieve social impact for children and families in a range of human service and education areas, with an emphasis on child welfare and early childhood service contexts. Allison is Professor of the Practice and Director of Implementation Practice at the School of Social Work, Faculty Fellow at the FPG Child Development Institute, and Adjunct Professor at the School of Global Public Health at The University of North Carolina-Chapel Hill. She is also an Adjunct Professor at the School of Medicine at Trinity College Dublin. Allison previously served as Director of the National Implementation Research Network and Lead of the Implementation Science Division at the FPG Child Development Institute where she also served as a Senior Research Scientist for 13 years. Allison’s research interests include the role of trust, power and relationships in evidence use, competencies for supporting implementation, and co-creation strategies to support sustainable change. She is particularly interested in the development of a workforce for supporting implementation in public systems. Allison is co-chair of the Institute on Implementation Practice and founding director of the Collaborative for Implementation Practice at UNC-Chapel Hill School of Social Work. She is the co-editor of the widely read volume Applying Implementation Science in Early Childhood Programs and Systems.

background

There is an increasing call for the advancement of a workforce capable of integrating implementation research – models, frameworks, and strategies – into practice to support evidence use, advance equity, and achieve improved population outcomes. Studies have identified plausible competencies for implementation practice (1, 2, 3). This William T. Grant funded study explored the use of competencies by professionals who support evidence use in human service systems and the conditions under which specific implementation strategies were perceived as most effective.

MEthod

A hybrid purposive-convenience sampling approach resulted in a sample of 17 individuals, each with more than 15 years’ experience providing implementation support. Data were collected via in-depth, semi-structured interviews. Core research questions included: What implementation support strategies are used to support the use of evidence? Under what conditions have specific implementation support strategies contributed to supporting evidence use? Data were analyzed using a qualitative content analysis approach.

results

Respondents reported using a range of strategies across domains to support evidence-use. Trusting relationships emerged as a ubiquitous fixture of the implementation support process. Respondents described trusting relationships as directly associated with successful implementation and use of evidence and bidirectionally associated with (and reinforcing of) all other implementation strategies.

Conclusion

Findings reflect that implementation support is a multi-faceted endeavor that requires a broad range of skills. Respondents enacted technical strategies (e.g., frequent interactions), while simultaneously carrying out relational strategies (e.g., empathy-driven exchanges). Relationships appear to be as important as technical strategies and may explain why perfectly offered implementation support at times remains unsuccessful in leading to sustained evidence use. Building a workforce capable of supporting evidence-use will require developing skills for building trusting relationships. Findings from this study have resulted in a model for trust building being tested by NJ’s Division of Children and Families with funding from the W.T. Grant Foundation.

Use of routine healthcare data in randomised implementation trials: a methodological systematic review

O13

PRESENter

Charis Xuan Xie
Charis-bio-pic

authors

Charis Xuan Xie, Lixin Sun, Elizabeth Ingram, Anna De Simoni, Sandra Eldridge, Hilary Pinnock, Clare Relton

Biography

Charis Xuan Xie is a PhD student in the Wellcome Trust Health Data in Practice programme at Queen Mary University of London. She holds an MSc in Health Information Systems from the University of Melbourne in Australia.

Prior to her PhD, she worked as a research assistant at Monash University, evaluating the accuracy of smartwatch technology for the diagnosis of Atrial Fibrillation. She then worked at The University of Sydney on a systematic review of the effectiveness of clinical dashboards on medication use and test ordering.

Charis’ research interests are primarily in the field of digital health, implementation science and health data science. Currently, her doctoral work explores the use of routine healthcare data in improving the efficiency of randomised implementation trials.

background

Routine healthcare data (RHD) are increasingly used in randomised controlled trials evaluating healthcare interventions. It can aid participant identification, outcome assessment and intervention delivery. Some trials evaluating the effectiveness of strategies designed to improve the uptake of evidence-based practice are referred to as implementation trials. However, little is known about RHD use in randomised implementation trials (RITs). This review aims to describe the methodological characteristics concerning how RHD have been used in RITs.

MEthod

We searched MEDLINE (Ovid), Cochrane Methodology Registry and Cochrane Central Register of Controlled Trials from Jan 2000 to Dec 2021, and manually searched protocols from trial registers. We included implementation trials and type II and type III hybrid effectiveness-implementation trials conducted using RHD. We conducted a mixed-method approach to extract quantitative and qualitative data and narratively synthesise findings.

results

We included 80 RITs, of which multicomponent implementation strategies were commonly evaluated (70.0%), as opposed to single strategies. The most frequently implemented evidence-based interventions were clinical guidelines (22.5%). Most trials assessed adoption as the implementation outcome (65.0%). The majority of trials used data from electronic health records (EHRs) (62.5%); RHD were predominantly used in a combination of participant identification, intervention delivery and outcome assessment (58.8%). Seven themes of reported rationales for using RHD were validating results, increasing efficiency, assessing outcomes, reducing research burden, improving quality of care, identifying study samples, and assessing representativeness. Four themes of barriers and facilitators were data quality, EHR systems, research governance and external factors (e.g. policy).

Conclusion

Identifying the implementation trials was difficult due to poor trial reporting. Further work is required to enhance the adoption of and adherence to existing guidelines on designing and reporting implementation studies. Additional work is needed to harmonise the language used in describing implementation strategies and implementation outcomes. Routine healthcare data are promising in supporting the implementation of evidence-based interventions. Data derived from EHRs have been widely used for participant identification, outcome assessment and intervention delivery. However, barriers exist that prevent routine data from achieving its full potential. Future research should focus on improving data quality and delivery, and optimising healthcare data systems.

Using behaviour change theory to assess intervention effectiveness in audit and feedback trials: A method for classifying and analysing interventions

O4

PRESENter

Vivi Antonopoulou
VA-photo

authors

Vivi Antonopoulou, Carly Meyer, Jacob Crawshaw, Fabiana Lorencatto, Justin Presseau, Kristin Konnyu, Jesmin Antony, Michelle Simeoni, Susan Michie, Jeremy Grimshaw & Noah Ivers

Biography

Vivi is a Research Fellow for the NIHR Behavioural Science Policy Research Unit (BSc PRU) based at UCL. Vivi’s current research focuses on optimising behaviour change interventions targeting healthcare professionals’ practice and on synthesising evidence to inform health-related recommendations and policies. Her research interests include using behaviour change theory and models for the design and development of effective interventions and the implementation of research evidence into practice with the aim to improve quality of service provision. Prior to working in this post, Vivi was involved in projects designing interventions aiming to change social work and social care professional practice and exploring the effectiveness of training, and in the evaluation of complex interventions in local authority settings. Vivi is a BPS Chartered Psychologist (CPsychol AFBPsS).

background

Audit and feedback (A&F) is a frequently used quality improvement strategy to improve the implementation of evidence-based practice in healthcare. There is consistent evidence that A&F interventions deliver modest, variable, but significant improvements in clinical outcomes [1]. We are in the process of conducting an updated Cochrane review comprising 293 randomized trials of A&F. As part of this update, we examined intervention content to better understand which components are associated with greater effect sizes. We have used the behaviour change technique (BCT) taxonomy to content analyse the trials and leverage existing behaviour change theories to highlight key constructs relevant to A&F. The aim of the present study was two-fold: (1) to map key constructs of selected behaviour change theories relevant to A&F to BCTs; and (2) to describe the extent to which randomised trials of A&F incorporate theory-informed BCTs.

MEthod

We selected five behaviour change theories relevant to A&F: Goal Setting theory, Control theory, Feedback Intervention theory, Health Action Process Approach and Social Cognitive theory. For each theory, theoretical constructs were identified and linked to BCTs. For cross-validation, two separate processes were applied: theory experts cross-checked the BCT mapping onto constructs and A&F experts judged these BCTs for their relevance to A&F practice. Theory-informed BCTs were compared with BCTs identified in the analysis of the A&F trials included in the forthcoming Review.

results

Preliminary results yielded 58 BCTs linked to constructs in one or more theories. The most frequently identified BCTs in theories were: ‘goal setting (behaviour)’, goal setting (outcome)’, ‘action planning’, ‘review behaviour goal’, and ‘review outcome goal’. In contrast, the most frequently identified BCTs in the A&F trials included in the review revealed ‘feedback’, ‘instruction’, and ‘social comparison’ to be the most frequently used.

Conclusion

Methodological considerations as well as implications for A&F research and practice will be discussed.

Using rapid qualitive inquiry for implementation support in a multinational study on infection prevention and control in neonatal intensive care

O32

PRESENter

Emanuela Nyantakyi
Design-ohne-Titel23

authors

Emanuela Nyantakyi, Marie-Therese Schultes, Julia Bielicki, Tuuli Metsvaht, Lauren Clack & the NeoIPC consortium

Biography

Emanuela Nyantakyi is a PhD Candidate at the Institute for Implementation Science in Health Care, University of Zurich. Her research integrates systems thinking approaches into implementation science research and is primarily focused on the European Union Horizon 2020 project NeoIPC (Neonatal Infection Prevention and Control). She holds a Bachelor of Science in Health Science from the Technological University of Munich and a Master of Science in Health Sciences with a concentration in Health Policy from the Vrije Universiteit Amsterdam.

background

The EU Horizon 2020 project NeoIPC aims to identify effective infection prevention and control interventions and corresponding implementation strategies for neonatal intensive care units (NICUs). In preparation of the trial, an implementation needs assessment survey with participating units in several European countries and South Africa was conducted. In the meantime, concerns among health professionals regarding the safety of the planned intervention and study design became apparent. A rapid qualitative approach was chosen to better understand these concerns and inform ongoing trial preparation.

MEthod

The survey was disseminated online to 22 participating NICUs and collected information regarding barriers and facilitators to the planned intervention based on scenarios with open response options. Two virtual focus groups (FGs) à 90 minutes were held. The FGs were centered around the relevance, efficacy, and safety of the planned intervention and potential concerns regarding the conduct of cluster randomized controlled trials (cRCTs) in NICUs. To quickly integrate the results into the project, data collection and analysis in both assessments were guided by a rapid qualitative approach using the CFIR framework based on Nevadal et al. [1].

results

Thirteen NICUs responded to the survey. The FGs were attended by nine pediatricians and neonatologists from six European countries. In both assessments, the evidence base for the planned intervention and aspects of its compatibility with routine practice were deemed primary barriers. Stakeholder engagement strategies were named as potential facilitators to implementation. Including nurses to determine feasibility (i.e., practice fit) of interventions was suggested in the FGs. No concerns regarding the conduct of cRCTs were raised.

Conclusion

In our study, a pragmatic qualitative approach of rapid data assessment and analysis provided valuable information to implementation design and project development. However, the homogeneity in our focus group participants showed a limited insight into routine care practice, which should be complemented by further assessments.

REFERENCES:
[1] Nevedal A, Reardon CM, Opra Widerquist MA et al. Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Implementation Sci. 2021; 16 (67). doi: 10.1186/s13012-021-01111-5