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Using segmented regression analysis of interrupted time series data to assess colonoscopy quality outcomes of a web-enhanced implementation toolkit to support evidence-based practices for bowel preparation: a study protocol.

Ramsey AT, Maki J, Prusaczyk B, Yan Y, Wang J, Lobb R - Implement Sci (2015)

Bottom Line: Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes.The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

View Article: PubMed Central - PubMed

Affiliation: Washington University Brown School of Social Work, 1 Brookings Dr., St. Louis, MO, 63130, USA. aramsey@wustl.edu.

ABSTRACT

Background: While there is convincing evidence on interventions to improve bowel preparation for patients, the evidence on how to implement these evidence-based practices (EBPs) in outpatient colonoscopy settings is less certain. The Strategies to Improve Colonoscopy (STIC) study compares the effect of two implementation strategies, physician education alone versus physician education plus an implementation toolkit for staff, on adoption of three EBPs (split-dosing of bowel preparation, low-literacy education, teach-back) to improve pre-procedure and intra-procedure quality measures. The implementation toolkit contains a staff education module, website containing tools to support staff in delivering EBPs, tailored patient education materials, and brief consultation with staff to determine how the EBPs can be integrated into the existing workflow. Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.

Methods/design: Participants will include all outpatient colonoscopy physicians, staff, and patients from a convenience sample of six endoscopy settings. Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes. We will assess the change in level and trends of clinical quality outcomes (i.e., adequacy of bowel preparation, adenoma detection) using segmented regression analysis of interrupted time series data with two groups (intervention and delayed start). Aim #2 will examine the influence of organizational readiness to change on EBP implementation. We use a PRECIS diagram to reflect the extent to which each indicator of the study was pragmatic versus explanatory, revealing a largely pragmatic study.

Discussion: Implementation challenges have already motivated several adaptations to the original plan, reflecting the nature of implementation in real-world healthcare settings. The pragmatic study responds to the evolving needs of its healthcare partners and allows for flexibility in intervention delivery, thereby informing clinical decision-making in real-world settings. The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

No MeSH data available.


Related in: MedlinePlus

Conceptual model of STIC study. Adapted from the Proctor et al. conceptual model of implementation research [36, 37]
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Fig1: Conceptual model of STIC study. Adapted from the Proctor et al. conceptual model of implementation research [36, 37]

Mentions: Addressing barriers to implementation of EBPs for bowel preparation can help reduce the substantial variation in colonoscopy outcomes found across healthcare settings. Several frameworks of implementation for interventions to improve health have emerged over the last decade [24, 25]. The Promoting Action on Research Implementation in Health Services (PARIHS) framework is among the most researched frameworks of implementation [26]. There is evidence to suggest that key factors of the PARIHS framework—perceptions of the evidence, context, and facilitation—are critical precursors to successful implementation of complex changes in healthcare settings (Fig. 1) [27, 24]. Two aspects of scientific evidence, relative advantage of the new intervention over an existing intervention [27] and compatibility with existing values and past experiences, are strongly correlated with adoption of interventions [28, 29]. Context refers to organizational culture and leadership [29, 25]. These contextual factors affect staffs’ capacity to facilitate implementation by encouraging analytical engagement in quality improvement processes [30]. Facilitation refers to the structures and processes in place to support change in clinical practice [29, 31]. When implementation efforts are interdependent across multiple levels of healthcare providers, as is expected in this study, context and facilitation are highly influenced by the structure and quality of the physician-staff relationship. As informed by leader-member exchange (LMX) theory, employees (i.e., staff) and supervisors (i.e., physicians) establish unique exchange relationships that contribute to employee work attitudes and performance (i.e., implementation of evidence-based colonoscopy care) [32]. Together, evidence, context, and facilitation contribute to organizations’ readiness to successfully implement change [24, 31]. Published reports on complex change initiatives suggest a median implementation success rate of only 33 % [24] due to factors such as false start of an intervention, staff resistance to implementation, or failure to implement an intervention [27]. Understanding the structure and quality of relationships between the physicians and implementers of patient education in endoscopy settings is important to developing strategies to increase adoption of EBPs. Our study 1) compares the effect of two implementation strategies on the adoption of EBPs to improve patient bowel preparation and 2) examines whether physician-team level aspects of readiness to change are associated with colonoscopy quality, patient, and implementation outcomes to gain a better understanding of the nature of implementation of pre-colonoscopy patient interventions in endoscopy settings.Fig. 1


Using segmented regression analysis of interrupted time series data to assess colonoscopy quality outcomes of a web-enhanced implementation toolkit to support evidence-based practices for bowel preparation: a study protocol.

Ramsey AT, Maki J, Prusaczyk B, Yan Y, Wang J, Lobb R - Implement Sci (2015)

Conceptual model of STIC study. Adapted from the Proctor et al. conceptual model of implementation research [36, 37]
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4465008&req=5

Fig1: Conceptual model of STIC study. Adapted from the Proctor et al. conceptual model of implementation research [36, 37]
Mentions: Addressing barriers to implementation of EBPs for bowel preparation can help reduce the substantial variation in colonoscopy outcomes found across healthcare settings. Several frameworks of implementation for interventions to improve health have emerged over the last decade [24, 25]. The Promoting Action on Research Implementation in Health Services (PARIHS) framework is among the most researched frameworks of implementation [26]. There is evidence to suggest that key factors of the PARIHS framework—perceptions of the evidence, context, and facilitation—are critical precursors to successful implementation of complex changes in healthcare settings (Fig. 1) [27, 24]. Two aspects of scientific evidence, relative advantage of the new intervention over an existing intervention [27] and compatibility with existing values and past experiences, are strongly correlated with adoption of interventions [28, 29]. Context refers to organizational culture and leadership [29, 25]. These contextual factors affect staffs’ capacity to facilitate implementation by encouraging analytical engagement in quality improvement processes [30]. Facilitation refers to the structures and processes in place to support change in clinical practice [29, 31]. When implementation efforts are interdependent across multiple levels of healthcare providers, as is expected in this study, context and facilitation are highly influenced by the structure and quality of the physician-staff relationship. As informed by leader-member exchange (LMX) theory, employees (i.e., staff) and supervisors (i.e., physicians) establish unique exchange relationships that contribute to employee work attitudes and performance (i.e., implementation of evidence-based colonoscopy care) [32]. Together, evidence, context, and facilitation contribute to organizations’ readiness to successfully implement change [24, 31]. Published reports on complex change initiatives suggest a median implementation success rate of only 33 % [24] due to factors such as false start of an intervention, staff resistance to implementation, or failure to implement an intervention [27]. Understanding the structure and quality of relationships between the physicians and implementers of patient education in endoscopy settings is important to developing strategies to increase adoption of EBPs. Our study 1) compares the effect of two implementation strategies on the adoption of EBPs to improve patient bowel preparation and 2) examines whether physician-team level aspects of readiness to change are associated with colonoscopy quality, patient, and implementation outcomes to gain a better understanding of the nature of implementation of pre-colonoscopy patient interventions in endoscopy settings.Fig. 1

Bottom Line: Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes.The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

View Article: PubMed Central - PubMed

Affiliation: Washington University Brown School of Social Work, 1 Brookings Dr., St. Louis, MO, 63130, USA. aramsey@wustl.edu.

ABSTRACT

Background: While there is convincing evidence on interventions to improve bowel preparation for patients, the evidence on how to implement these evidence-based practices (EBPs) in outpatient colonoscopy settings is less certain. The Strategies to Improve Colonoscopy (STIC) study compares the effect of two implementation strategies, physician education alone versus physician education plus an implementation toolkit for staff, on adoption of three EBPs (split-dosing of bowel preparation, low-literacy education, teach-back) to improve pre-procedure and intra-procedure quality measures. The implementation toolkit contains a staff education module, website containing tools to support staff in delivering EBPs, tailored patient education materials, and brief consultation with staff to determine how the EBPs can be integrated into the existing workflow. Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.

Methods/design: Participants will include all outpatient colonoscopy physicians, staff, and patients from a convenience sample of six endoscopy settings. Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes. We will assess the change in level and trends of clinical quality outcomes (i.e., adequacy of bowel preparation, adenoma detection) using segmented regression analysis of interrupted time series data with two groups (intervention and delayed start). Aim #2 will examine the influence of organizational readiness to change on EBP implementation. We use a PRECIS diagram to reflect the extent to which each indicator of the study was pragmatic versus explanatory, revealing a largely pragmatic study.

Discussion: Implementation challenges have already motivated several adaptations to the original plan, reflecting the nature of implementation in real-world healthcare settings. The pragmatic study responds to the evolving needs of its healthcare partners and allows for flexibility in intervention delivery, thereby informing clinical decision-making in real-world settings. The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

No MeSH data available.


Related in: MedlinePlus