Dataset Information

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.

ABSTRACT:

Background

A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers.

Methods

Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices.

Results

Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD?=?4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants.

Conclusions

The wide heterogeneity of endorsements obtained in this study's task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study's results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

SUBMITTER: Waltz TJ

PROVIDER: S-EPMC6489173 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

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Publications

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.

Waltz Thomas J TJ Powell Byron J BJ Fernández María E ME Abadie Brenton B Damschroder Laura J LJ

Implementation science : IS 20190429 1

<h4>Background</h4>A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) ...[more]

PMID: 31036028

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Project description:BackgroundCognitive behavioral therapy for insomnia (CBT-I) is a highly effective nonpharmacological intervention that is widely considered the gold standard for insomnia treatment. Insomnia is a prevalent and debilitating public health concern. Up to one third of the general population struggles with chronic insomnia, greatly increasing the risk for chronic pain and inflammation, depression and suicide, and cognitive decline. Over the last 10 years, the Veterans Health Administration (VHA) evidence-based psychotherapy training program has trained nearly 1000 providers to deliver CBT-I in hospitals and clinics nationwide. Despite increased access, most patients with insomnia receive sleeping medications instead of CBT-I. This is particularly concerning for vulnerable populations, like older adults, who may be at increased risk of harms from medications. The goal of this study was to obtain a broad range of perspectives on CBT-I implementation from providers who commonly utilize and deliver CBT-I. This work identifies barriers and successful strategies used to overcome these barriers to guide future implementation efforts promoting evidence-based sleep care.MethodsSemi-structured interviews, using the Consolidated Framework for Implementation Research (CFIR) as a guide, were conducted with 17 providers from five Veterans Affairs (VA) facilities (8 primary care physicians, 4 primary care psychologists, and 5 CBT-I coordinators). We used a thematic analysis approach in which common ideas were identified across interviews and then grouped into larger conceptual themes. Data were concurrently collected and analyzed with rapid assessment process (RAP) techniques.ResultsFindings suggested implementation barriers and facilitators related to the CFIR constructs of intervention characteristic (e.g., providers unfamiliar with primary evidence of CBT-I effectiveness), inner setting (e.g., sleep as a low relative priority in primary care), and outer setting (e.g., lack of external incentives for increasing CBT-I use), as well as several successful strategies, including use of local champions and supportive opinion leaders.ConclusionsThese findings suggest promising opportunities to improve implementation of CBT-I, especially at facilities with less well-established CBT-I programs. Formal implementation trials are needed to systematically determine the real-world impact of strategies such as enlisting CBT-I champions, informing opinion leaders about CBT-I services, and promoting network weaving among primary care, mental health, and sleep clinics.

Project description:BACKGROUND:The Choosing Wisely campaign has spread to many countries. Methods for developing recommendations are inconsistent. We describe our process of developing such recommendations from a comprehensive national set of clinical practice guidelines (Current Care, CC) and the results of a one-year Choosing Wisely Finland project. METHODS:Two of the authors drafted the quality and process criteria for all the Choosing Wisely Finland recommendations. The quality criteria were relevance, feasibility, evidence-based and strength. These were discussed in editors' meetings and subsequently revised. Two different processes for developing recommendations within national clinical practice guidelines were designed and piloted (processes A and B). Process A was based on a published guideline. The recommendations are drafted by an editor and revised and approved by the guideline development group. In process B the development of the recommendations is integrated with guideline production or update. Choosing Wisely recommendations were then drafted for half of the published CC Guidelines. An additional process (process C) was designed for producing independent recommendations outside a guideline. RESULTS:At least one Choosing Wisely recommendation could be identified from 39 out of 52 reviewed guidelines. Of the 106 recommendations drafted, 62 (58%) were accepted for publication. The main reasons for rejection were inability to give a strong recommendation (n?=?18, 41%) and insufficient relevance (n?=?14, 32%). Two thirds (n?=?41, 66%) of the published recommendations were based on high to moderate level of evidence, and 18% (n?=?11) on low or very low level of evidence, whereas for the rest, the quality of evidence was not critically appraised. CONCLUSIONS:Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations.

Dataset Information

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.

Background

Methods

Results

Conclusions

Publications

Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.

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