Search

Objective: High rates of overweight and obesity (70%) among US veterans pose a significant threat of obesity-related chronic disease and disability. The purpose of this pilot study was to demonstrate feasibility and impact of a phone-based small-change weight loss intervention (ASPIRE-VA) with veterans.Methods: Participants received a pedometer, food log book, and treatment manual outlining the small change program. Participants then scheduled weekly phone calls with a lifestyle coach, during which they reviewed the prior week's goals and developed new goals for the following week. Primary outcome was weight loss measured at 12 weeks, compared to baseline.Results: Fourteen sedentary (4471+/-2315 steps per day), obese (37.0+/-4.2 BMI), middle aged (53.8+/-12.5) male (64%) and female (36%) participants were enrolled. At 12 weeks participants exhibited significant weight loss (-3.8+/-3.6 kg; p=.002) and increased intake of fruits and vegetables (+2.2+/-3.1 daily servings; p=.03); though no change in walking (+786+/-2288 daily steps; p=.24).Conclusion: Results suggest that a phone-based small change program is feasible and beneficial for promoting weight loss in overweight/obese veterans.Practice Implications: This telephone-based program has the potential to reduce rates of overweight and obesity among veterans and thus prevent and improve prognosis of associated chronic conditions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although 20% or more of healthcare-associated infections can be prevented, many hospitals have not implemented practices known to reduce infections. We explored the types and numbers of champions who lead efforts to implement best practices to prevent hospital-acquired infection in US hospitals. METHODS: Qualitative analyses were conducted within a multisite, sequential mixed methods study of infection prevention practices in Veteran Affairs and non-Veteran Affairs hospitals in the USA. The first phase included telephone interviews conducted in 2005-2006 with 38 individuals at 14 purposively selected hospitals. The second phase used findings from phase 1 to select six hospitals for site visits and interviews with another 48 individuals in 2006-2007. RESULTS: It was possible for a single well-placed champion to implement a new technology, but more than one champion was needed when an improvement required people to change behaviours. Although the behavioural change itself may appear to be an inexpensive and simple solution, implementation was often more complicated than changing technology because behavioural changes required interprofessional coalitions working together. Champions in hospitals with low-quality working relationships across units or professions had a particularly challenging time implementing behavioural change. Merely appointing champions is ineffective; rather, successful champions tended to be intrinsically motivated and enthusiastic about the practices they promoted. Even when broad implementation is stymied, champions can implement change within their own sphere of influence. CONCLUSIONS: The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Person tradeoff (PTO) elicitations assess people's values for health states by asking them to compare the value of treatment programs. For example, people might be asked how many patients need to be cured of health condition X to equal the benefit of curing 100 people of condition Y. However, when faced with PTO elicitations, people frequently refuse to make quantifiable tradeoffs, exhibiting 2 kinds of refusals: 1) They say that 2 treatment programs have equal value, that curing 100 of X is just as good as curing 100 of Y, even if X is a less serious condition than Y, or 2) they say that the 2 programs are incomparable, that millions of people need to be cured of X to be as good as curing 100 of Y. The authors explore whether people would be more willing to make tradeoffs if the focus was changed from trading off groups of patients to choosing the best decision or evaluating treatment benefits. DESIGN: . Two randomized trials used diverse samples (N=2400) via the Internet to test for the effect of perspective on refusal rates. The authors predicted that perspectives that removed people from decision-making roles would increase their willingness make tradeoffs. RESULTS: Contrary to expectations, refusal rates increased when people were removed from decision-making roles. In fact, the more pressure put on people to make a decision, the less likely they were to refuse to make tradeoffs. CONCLUSION: To reduce PTO refusals, it is best to adopt a decision-maker perspective. [ABSTRACT FROM AUTHOR]

The federal Privacy Rule, implemented in the United States in 2003, as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), created new restrictions on the release of medical information for research. Many believe that its restrictions have fallen disproportionately on researchers prompting some to call for changes to the Rule. Here we ask what patients think about researchers' access to medical records, and what influences these opinions. A sample of 217 patients from 4 Veteran Affairs (VA) facilities deliberated in small groups at each location with the opportunity to question experts and inform themselves about privacy issues related to medical records research. After extensive deliberation, these patients were united in their inclination to share their medical records for research. Yet they were also united in their recommendations to institute procedures that would give them more control over whether and how their medical records are used for research. We integrated qualitative and quantitative results to derive a better understanding of this apparent paradox. Our findings can best be presented as answers to questions related to five dimensions of trust: Patients' trust in VA researchers was the most powerful determinant of the kind of control they want over their medical records. More specifically, those who had lower trust in VA researchers were more likely to recommend a more stringent process for obtaining individual consent. Insights on the critical role of trust suggest actions that researchers and others can take to more fully engage patients in research. [ABSTRACT FROM AUTHOR]

Objective: To test effectiveness of the LEAP (Learn Engage Act Process) Program on engaging frontline Veteran Health Administration (VHA) medical center teams in continuous quality improvement (QI), a core capability for learning health systems., Data Sources and Study Setting: Data sources included VHA electronic health record (EHR) data, surveys, and LEAP coaching field notes., Study Design: A staggered difference-in-differences study was conducted. Fifty-five facilities participated in LEAP across eight randomly assigned clusters of 6-8 facilities per cluster over 2 years. Non-participating facilities were used as controls. A MOVE! weight management program team completed a Plan-Do-Study-Act cycle of change supported by learning curriculum, coaching, and virtual collaboratives in LEAP facilities. Primary outcome was program reach to Veterans. A mixed-effects model compared pre- versus post-LEAP periods for LEAP versus control facilities. LEAP adherence, satisfaction, and cost to deliver LEAP were evaluated., Data Collection/extraction Methods: Thirty months of facility-level EHR MOVE! enrollment data were included in analyses. LEAP Satisfaction and QI skills were elicited via surveys at baseline and 6-month post-LEAP., Principal Findings: Fifty-five facilities were randomly assigned to eight time-period-based clusters to receive LEAP (71% completed LEAP) and 82 non-participating facilities were randomly assigned as controls. Reach in LEAP and control facilities was comparable in the 12-month pre-LEAP period (p = 0.07). Though LEAP facilities experienced slower decline in reach in the 12-month post-LEAP period compared with controls (p < 0.001), this is likely due to unexplained fluctuations in controls. For LEAP facilities, satisfaction was high (all mean ratings >4 on a 5-point scale), self-reported use of QI methods increased significantly (p-values <0.05) 6 months post-LEAP, and delivery cost was $4024 per facility-based team., Conclusion: Control facilities experienced declining reach in the 12-month post-LEAP period, but LEAP facilities did not, plus they reported higher engagement in QI, an essential capability for learning health systems., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objectives: To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence-based lifestyle intervention known as the Diabetes Prevention Program (DPP)., Data Sources and Study Setting: 2012-2024 VA administrative and survey data., Study Design: This is a summary of findings and impacts from four effectiveness-implementation projects focused on in-person and/or online DPP across VA sites., Data Collection/extraction Methods: Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes-Mellitus Quality Enhancement Research Initiative (QUERI-DM) Diabetes Prevention Program (VA DPP) Trial, QUERI-DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program., Principal Findings: Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender-tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services., Conclusions: Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Background: Patient safety culture (PSC) fosters an environment of trust where people are encouraged to share information to promote psychological safety. To measure PSC, the Veteran's Health Administration (VHA) developed a PSC survey consisting of 20 items administered to all VHA employees. The survey comprises four scales: (1) risk identification and Just Culture, (2) error transparency and mitigation, (3) supervisor communication and trust, and (4) team cohesion and engagement. Our objective was to compare the PSC survey data to qualitative data regarding high reliability organization (HRO) implementation from four purposively selected VHA hospitals to assess how it manifests and converges., Methods: Qualitative data focused on understanding HRO implementation efforts were collected from key informants between 2019 and 2020 at 4 of the 18 VHA HRO implementation hospitals. To explore the extent and manifestation of each of the PSC scales among the 4 sites, we combined the qualitative data with the PSC survey data from each hospital using a joint display., Results: Survey responses were significantly different between the 4 hospitals for all 4 PSC scales. Of the 20 PSC survey items, 12 (60.0%) significantly differed across the 4 hospitals. For example, we saw cross-hospital differences in the following survey items: "We are given feedback about changes put into place based on event reports" and "We take the time to identify and assess risks to patient safety." Qualitative data supported manifestations for 80.0% (16/20) of PSC individual survey items among hospitals., Conclusion: The authors found that the qualitative data manifestations were well aligned with the VHA PSC scales, but relationships were not always consistent between data sources. Further research is necessary to elucidate these relationships., (Published by Elsevier Inc.)

Objective: The increasing prevalence of and inequities in childhood obesity demand improved access to effective treatment. The SmartMoves curriculum used in Bright Bodies, a proven-effective, intensive health behavior and lifestyle treatment (IHBLT), was disseminated to ≥30 US sites from 2003 to 2018. We aimed to identify barriers to and facilitators of IHBLT implementation/sustainment., Methods: We surveyed and interviewed key informants about experiences acquiring/implementing SmartMoves. In parallel, we analyzed and then integrated survey findings and themes from interviews using the constant comparative method., Results: Participants from 16 sites (53%) completed surveys, and 12 participants at 10 sites completed interviews. The 11 sites (63%) that implemented SmartMoves varied in both use of training opportunities/materials and fidelity to program components. In interviews, demand for obesity programming, organizational priorities, and partnerships facilitated implementation. Seven sites discontinued SmartMoves prior to the COVID-19 pandemic. Funding insecurity and insufficient staffing emerged as dominant barriers to implementation/sustainment discussed by all interviewees, and some also noted participants' competing demands and the program's fit with population as challenges., Conclusions: System- and organizational-level barriers impeded sustainment of an evidence-based IHBLT program. Adequate funding could enable sufficient staffing and training to promote fidelity to the intervention's core functions and adaptation to fit local populations/context., (© 2024 The Obesity Society.)

Background: Electronic health record-based clinical decision support (CDS) tools can facilitate the adoption of evidence into practice. Yet, the impact of CDS beyond single-site implementation is often limited by dissemination and implementation barriers related to site- and user-specific variation in workflows and behaviors. The translation of evidence-based CDS from initial development to implementation in heterogeneous environments requires a framework that assures careful balancing of fidelity to core functional elements with adaptations to ensure compatibility with new contexts., Objective: This study aims to develop and apply a framework to guide tailoring and implementing CDS across diverse clinical settings., Methods: In preparation for a multisite trial implementing CDS for pediatric overweight or obesity in primary care, we developed the User-Centered Framework for Implementation of Technology (UFIT), a framework that integrates principles from user-centered design (UCD), human factors/ergonomics theories, and implementation science to guide both CDS adaptation and tailoring of related implementation strategies. Our transdisciplinary study team conducted semistructured interviews with pediatric primary care clinicians and a diverse group of stakeholders from 3 health systems in the northeastern, midwestern, and southeastern United States to inform and apply the framework for our formative evaluation., Results: We conducted 41 qualitative interviews with primary care clinicians (n=21) and other stakeholders (n=20). Our workflow analysis found 3 primary ways in which clinicians interact with the electronic health record during primary care well-child visits identifying opportunities for decision support. Additionally, we identified differences in practice patterns across contexts necessitating a multiprong design approach to support a variety of workflows, user needs, preferences, and implementation strategies., Conclusions: UFIT integrates theories and guidance from UCD, human factors/ergonomics, and implementation science to promote fit with local contexts for optimal outcomes. The components of UFIT were used to guide the development of Improving Pediatric Obesity Practice Using Prompts, an integrated package comprising CDS for obesity or overweight treatment with tailored implementation strategies., Trial Registration: ClinicalTrials.gov NCT05627011; https://clinicaltrials.gov/study/NCT05627011., (©Jessica Ray, Emily Benjamin Finn, Hollyce Tyrrell, Carlin F Aloe, Eliana M Perrin, Charles T Wood, Dean S Miner, Randall Grout, Jeremy J Michel, Laura J Damschroder, Mona Sharifi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 21.05.2024.)

Background: The Veterans Health Administration (VHA) is the United States largest learning health system. The Diffusion of Excellence (DoE) program is a large-scale model of diffusion that identifies and diffuses evidence-informed practices across VHA. During the period of 2016-2021, 57 evidence-informed practices were implemented across 82 VHA facilities. This setting provides a unique opportunity to understand sustainment determinants and pathways. Our objective was to characterize the longitudinal pathways of practices as they transition from initial implementation to long-term sustainment at each facility., Methods: A longitudinal, mixed-methods evaluation of 82 VHA facilities. Eighty-two facility representatives, chosen by leadership as points-of-contact for 57 DoE practices, were eligible for post-implementation interviews and annual sustainment surveys. Primary outcomes (implementation, sustainment), and secondary outcomes (institutionalization, effectiveness, anticipated sustainment) at four time-points were collected. We performed descriptive statistics and directed content analysis using Hailemariam et al.'s factors influencing sustainment., Results: After approximately five years post-implementation (e.g., 2021 sustainment outcomes), of the 82 facilities, about one-third fully sustained their practice compared to one-third that did not fully sustain their practice because it was in a "liminal" stage (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of facilities had missing 2021 sustainment outcomes. A higher percentage of facilities (70%) had inconsistent primary outcomes (changing over time) compared to facilities (30%) with consistent primary outcomes (same over time). Thirty-four percent of facilities with sustained practices reported resilience since they overcame implementation and sustainment barriers. Facilities with sustained practices reported more positive secondary outcomes compared to those that did not sustain their practice. Key factors facilitating practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, sufficient workforce, and adaptation/alignment with local context. Key factors hindering practice sustainment included: insufficient workforce, not able to maintain practice fidelity/integrity, critical incidents related to the COVID-19 pandemic, organizational leadership did not support sustainment of practice, and no ongoing support., Conclusions: We identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment outcomes. This longitudinal evaluation contributes to understanding impacts of the DoE program, including return on investment, achieving learning health system goals, and insights into achieving high-quality healthcare in VHA., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA., Methods: Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators., Results: In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank., Conclusion: DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care., Competing Interests: AS was employed by Agile Six Applications, Inc. All authors have been employees or contractors of the United States Department of Veterans Affairs., (© 2024 Jackson, Fix, White, Cutrona, Reardon, Damschroder, Burns, DeLaughter, Opra Widerquist, Arasim, Lindquist, Gifford, King, Kaitz, Jasuja, Hogan, Lopez, Henderson, Fitzgerald, Goetschius, Hagan, McCoy, Seelig and Nevedal.)

Objective: To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers., Design: Qualitative semistructured interviews., Setting: The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare., Participants: We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders., Methods: Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR., Results: We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff., Conclusion: Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.

Background Since 2015, the Veterans Health Administration (VHA) Diffusion of Excellence Program has supported spread of practices developed by frontline employees. Shark Tank-style competitions encourage "Sharks" nationwide (VHA medical center/regional directors) to bid for the opportunity to implement practices at their institutions. Methods The authors evaluated bidding strategies (2016-2020), developing the "QuickView" practice comparator to promote informed bidding. Program leaders distributed QuickView and revised versions in subsequent competitions. Our team utilized in-person observation, online chats after the competition, bidder interviews, and bid analysis to evaluate QuickView use. Bids were ranked based on demonstrated understanding of resources required for practice implementation. Results Sharks stated that QuickView supported preparation before the competition and suggested improvements. Our revised tool reported necessary staff time and incorporated a "WishList" from practice finalists detailing minimum requirements for successful implementation. Bids from later years reflected increased review of facilities' current states before the competition and increased understanding of the resources needed for implementation. Percentage of bids describing local need for the practice rose from 2016 to 2020: 4.7% (6/127); 62.1% (54/87); 78.3% (36/46); 80.6% (29/36); 89.7% (26/29). Percentage of bids committing specific resources rose following QuickView introduction: 81.1% (103/127) in 2016, 69.0% (60/87) in 2017, then 73.9% (34/46) in 2018, 88.9% (32/36) in 2019, and 89.7% (26/29) in 2020. Discussion In the years following QuickView/WishList implementation, bids reflected increased assessment before the competition of both local needs and available resources. Conclusion Selection of a new practice for implementation requires an understanding of local need, necessary resources, and fit. QuickView and WishList appear to support these determinations., Competing Interests: Conflicts of Interest None declared

Introduction: Cancer clinical trials can be considered evidence-based interventions with substantial benefits, but suffer from poor implementation leading to low enrollment and frequent failure. Applying implementation science approaches such as outcomes frameworks to the trial context could aid in contextualizing and evaluating trial improvement strategies. However, the acceptability and appropriateness of these adapted outcomes to trial stakeholders are unclear. For these reasons, we interviewed cancer clinical trial physician stakeholders to explore how they perceive and address clinical trial implementation outcomes., Methods: We purposively selected 15 cancer clinical trial physician stakeholders from our institution representing different specialties, trial roles, and trial sponsor types. We performed semi-structured interviews to explore a previous adaptation of Proctor's Implementation Outcomes Framework to the clinical trial context. Emergent themes from each outcome were developed., Results: The implementation outcomes were well understood and applicable (i.e., appropriate and acceptable) to clinical trial stakeholders. We describe cancer clinical trial physician stakeholder understanding of these outcomes and current application of these concepts. Trial feasibility and implementation cost were felt to be most critical to trial design and implementation. Trial penetration was most difficult to measure, primarily due to eligible patient identification. In general, we found that formal methods for trial improvement and trial implementation evaluation were poorly developed. Cancer clinical trial physician stakeholders referred to some design and implementation techniques used to improve trials, but these were infrequently formally evaluated or theory-based., Conclusion: Implementation outcomes adapted to the trial context were acceptable and appropriate to cancer clinical trial physician stakeholders. Use of these outcomes could facilitate the evaluation and design of clinical trial improvement interventions. Additionally, these outcomes highlight potential areas for the development of new tools, for example informatics solutions, to improve the evaluation and implementation of clinical trials., (© 2023. The Author(s).)

Background: The Consolidated Framework for Implementation Research (CFIR) is a determinant framework that can be used to guide context assessment prior to implementing change. Though a few quantitative measurement instruments have been developed based on the CFIR, most assessments using the CFIR have relied on qualitative methods. One challenge to measurement is to translate conceptual constructs which are often described using highly abstract, technical language into lay language that is clear, concise, and meaningful. The purpose of this paper is to document methods to develop a freely available pragmatic context assessment tool (pCAT). The pCAT is based on the CFIR and designed for frontline quality improvement teams as an abbreviated assessment of local facilitators and barriers in a clinical setting., Methods: Twenty-seven interviews using the Think Aloud method (asking participants to verbalize thoughts as they respond to assessment questions) were conducted with frontline employees to improve a pilot version of the pCAT. Interviews were recorded and transcribed verbatim; the CFIR guided coding and analyses., Results: Participants identified several areas where language in the pCAT needed to be modified, clarified, or allow more nuance to increase usefulness for frontline employees. Participants found it easier to respond to questions when they had a recent, specific project in mind. Potential barriers and facilitators tend to be unique to each specific improvement. Participants also identified missing concepts or that were conflated, leading to refinements that made the pCAT more understandable, accurate, and useful., Conclusions: The pCAT is designed to be practical, using everyday language familiar to frontline employees. The pCAT is short (14 items), freely available, does not require research expertise or experience. It is designed to draw on the knowledge of individuals most familiar with their own clinical context. The pCAT has been available online for approximately two years and has generated a relatively high level of interest indicating potential usefulness of the tool., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management., (Published by Oxford University Press on behalf of the Society of Behavioral Medicine 2022.)

Background: Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework., Methods: User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2., Results: The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent (n = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation., Conclusion: The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances., (© 2022. The Author(s).)

Background: Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials., Main Text: We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research., Conclusions: Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing., (© 2022. The Author(s).)

Background: The Veterans Health Administration (VHA) is the largest integrated health system in the U.S. and has identified the learning health system as a strategic priority. Clinicians and staff engaging in active learning through continuous quality improvement (QI) is a key pillar for learning system maturity. An interdisciplinary frontline team at a VHA medical center participated in the Learn. Engage. Act. Process. (LEAP) virtual coaching program to learn how to conduct multidisciplinary team-based QI cycles of change. These clinicians lead and deliver the MOVE! weight management program, an evidence-based comprehensive lifestyle intervention. The team worked to continuously improve patient weight loss by engaging in incremental learning cycles of change. The aim of this study is to tell the story of this team's learning experience and the resulting positive reinforcing loop with patient outcomes., Methods: This is a mixed methods case study description of one team that participated in the LEAP Program that provides hands-on QI learning for frontline teams with virtual coaching and a structured curriculum. Autoethnographic qualitative descriptions of team experiences over time illustrate this team's continued engagement in learning loops. Multilevel linear modeling was used to assess patient outcomes before vs after the team's participation in LEAP., Results: The team's participation in LEAP provided a set of fundamental QI skills and established a commitment to continual learning. Incremental improvements led to significant weight loss for patients who participated in MOVE! after the team completed LEAP (mean = 9.80 pounds; SD 10.43) compared to the pre-LEAP time period (mean = -6.83 pounds; SD 9.63)., Conclusions: Despite competing priorities and time limitations, this team's experiences provide a positive vision of how team engagement in data-driven continuous learning is feasible at the frontline and can lead to higher job satisfaction and stronger teams. These types of team activities provide much-needed backbone to being a mature learning health system., Competing Interests: All authors report that they have no conflicts of interest to report., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.)

Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise., (© 2022 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Background: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels., Objective: The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices., Methods: The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement., Results: Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process)., Conclusions: Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic., (©Jordan B Sparks, Mandi L Klamerus, Tanner J Caverly, Sarah E Skurla, Timothy P Hofer, Eve A Kerr, Steven J Bernstein, Laura J Damschroder. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2022.)

Background: The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies., Methods: For each trial, we will recruit 8-12 clinics (24-36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act., Process: (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently., Discussion: MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings., Trial Registration: ClinicalTrials.gov: NCT05065502 . Registered October 4, 2021-retrospectively registered., (© 2022. The Author(s).)

Introduction: Engaging patients and frontline clinicians in re-designing clinical care is essential for improving care delivery in a complex clinical environment. This study sought to assess an innovative user-centered design approach to improving clinical care quality, focusing on the use cases of de-intensifying non-beneficial care within the following areas: (1) de-intensifying diabetes treatment in high-risk patients; (2) stopping screening for carotid artery stenosis in asymptomatic patients; and (3) stopping colorectal cancer screening in average-risk, older adults., Methods: The user-centered design approach, consisting of patient and patient-clinician charrettes (defined as intensive workshops where key stakeholders collaborate to develop creative solutions to a specific problem) and participant surveys, has been described previously. Following the charrettes, we used inductive coding to identify and categorize themes emerging from the de-intensification ideas prioritized by participants as well as facilitator notes and audio recordings from the charrettes., Results: Thirty-five patients participated in the patient design charrettes, generating 134 unique de-intensification ideas and prioritizing 32, which were then distilled into six patient-generated principles of de-intensification by the study team. These principles provided a starting point for a subsequent patient-clinician charrette. In this follow-up charrette, 9 patients who had participated in an earlier patient design charrette collaborated with 7 clinicians to generate 63 potential de-intensification solutions. Six of these potential solutions were developed into multi-faceted, fully operationalized de-intensification strategies., Discussion: The de-intensification strategies that patients and clinicians prioritized and operationalized during the co-design charrette process were detailed and multi-faceted. Each component of a strategy had a rationale based on feasibility, practical considerations, and ways of overcoming barriers. The charrette-based process may be a useful way to engage clinicians and patients in developing the complex and multi-faceted strategies needed to improve care delivery., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: In this study we sought to explore the possibility of using patient centered care (PCC) documentation as a measure of the delivery of PCC in a health system., Methods: We first selected 6 VA medical centers based on their scores for a measure of support for self-management subscale from a national patient satisfaction survey (the Survey for Healthcare Experience-Patients). We accessed clinical notes related to either smoking cessation or weight management consults. We then annotated this dataset of notes for documentation of PCC concepts including: patient goals, provider support for goal progress, social context, shared decision making, mention of caregivers, and use of the patient's voice. We examined the association of documentation of PCC with patients' perception of support for self-management with regression analyses., Results: Two health centers had < 50 notes related to either tobacco cessation or weight management consults and were removed from further analysis. The resulting dataset includes 477 notes related to 311 patients total from 4 medical centers. For a majority of patients (201 out of 311; 64.8%) at least one PCC concept was present in their clinical notes. The most common PCC concepts documented were patient goals (patients n = 126; 63% clinical notes n = 302; 63%), patient voice (patients n = 165, 82%; clinical notes n = 323, 68%), social context (patients n = 105, 52%; clinical notes n = 181, 38%), and provider support for goal progress (patients n = 124, 62%; clinical notes n = 191, 40%). Documentation of goals for weight loss notes was greater at health centers with higher satisfaction scores compared to low. No such relationship was found for notes related to tobacco cessation., Conclusion: Providers document PCC concepts in their clinical notes. In this pilot study we explored the feasibility of using this data as a means to measure the degree to which care in a health center is patient centered., Practice Implications: clinical EHR notes are a rich source of information about PCC that could potentially be used to assess PCC over time and across systems with scalable technologies such as natural language processing., (© 2022. The Author(s).)

Background: Health care organizations increasingly depend on business intelligence tools, including "dashboards," to capture, analyze, and present data on performance metrics. Ideally, dashboards allow users to quickly visualize actionable data to inform and optimize clinical and organizational performance. In reality, dashboards are typically embedded in complex health care organizations with massive data streams and end users with distinct needs. Thus, designing effective dashboards is a challenging task and theoretical underpinnings of health care dashboards are poorly characterized; even the concept of the dashboard remains ill-defined. Researchers, informaticists, clinical managers, and health care administrators will benefit from a clearer understanding of how dashboards have been developed, implemented, and evaluated, and how the design, end user, and context influence their uptake and effectiveness., Objective: This scoping review first aims to survey the vast published literature of "dashboards" to describe where, why, and for whom they are used in health care settings, as well as how they are developed, implemented, and evaluated. Further, we will examine how dashboard design and content is informed by intended purpose and end users., Methods: In July 2020, we searched MEDLINE, Embase, Web of Science, and the Cochrane Library for peer-reviewed literature using a targeted strategy developed with a research librarian and retrieved 5188 results. Following deduplication, 3306 studies were screened in duplicate for title and abstract. Any abstracts mentioning a health care dashboard were retrieved in full text and are undergoing duplicate review for eligibility. Articles will be included for data extraction and analysis if they describe the development, implementation, or evaluation of a dashboard that was successfully used in routine workflow. Articles will be excluded if they were published before 2015, the full text is unavailable, they are in a non-English language, or they describe dashboards used for public health tracking, in settings where direct patient care is not provided, or in undergraduate medical education. Any discrepancies in eligibility determination will be adjudicated by a third reviewer. We chose to focus on articles published after 2015 and those that describe dashboards that were successfully used in routine practice to identify the most recent and relevant literature to support future dashboard development in the rapidly evolving field of health care informatics., Results: All articles have undergone dual review for title and abstract, with a total of 2019 articles mentioning use of a health care dashboard retrieved in full text for further review. We are currently reviewing all full-text articles in duplicate. We aim to publish findings by mid-2022. Findings will be reported following guidance from the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist., Conclusions: This scoping review will provide stakeholders with an overview of existing dashboard tools, highlighting the ways in which dashboards have been developed, implemented, and evaluated in different settings and for different end user groups, and identify potential research gaps. Findings will guide efforts to design and use dashboards in the health care sector more effectively., International Registered Report Identifier (irrid): DERR1-10.2196/34894., (©Danielle Helminski, Jacob E Kurlander, Anjana Deep Renji, Jeremy B Sussman, Paul N Pfeiffer, Marisa L Conte, Oliver J Gadabu, Alex N Kokaly, Rebecca Goldberg, Allison Ranusch, Laura J Damschroder, Zach Landis-Lewis. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 02.03.2022.)

Background: The challenges of implementing evidence-based innovations (EBIs) are widely recognized among practitioners and researchers. Context, broadly defined as everything outside the EBI, includes the dynamic and diverse array of forces working for or against implementation efforts. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely used frameworks to guide assessment of contextual determinants of implementation. The original 2009 article invited critique in recognition for the need for the framework to evolve. As implementation science has matured, gaps in the CFIR have been identified and updates are needed. Our team is developing the CFIR 2.0 based on a literature review and follow-up survey with authors. We propose an Outcomes Addendum to the CFIR to address recommendations from these sources to include outcomes in the framework., Main Text: We conducted a literature review and surveyed corresponding authors of included articles to identify recommendations for the CFIR. There were recommendations to add both implementation and innovation outcomes from these sources. Based on these recommendations, we make conceptual distinctions between (1) anticipated implementation outcomes and actual implementation outcomes, (2) implementation outcomes and innovation outcomes, and (3) CFIR-based implementation determinants and innovation determinants., Conclusion: An Outcomes Addendum to the CFIR is proposed. Our goal is to offer clear conceptual distinctions between types of outcomes for use with the CFIR, and perhaps other determinant implementation frameworks as well. These distinctions can help bring clarity as researchers consider which outcomes are most appropriate to evaluate in their research. We hope that sharing this in advance will generate feedback and debate about the merits of our proposed addendum., (© 2022. The Author(s).)

Objective: To examine how individual steward characteristics (eg, steward role, sex, and specialized training) are associated with their views of antimicrobial stewardship program (ASP) implementation at their institution., Design: Descriptive survey from a mixed-methods study., Setting: Two large national healthcare systems; the Veterans' Health Administration (VA) (n = 134 hospitals) and Intermountain Healthcare (IHC; n = 20 hospitals)., Participants: We sent the survey to 329 antibiotic stewards serving in 154 hospitals; 152 were physicians and 177 were pharmacists. In total, 118 pharmacists and 64 physicians from 126 hospitals responded., Methods: The survey was grounded in constructs of the Consolidated Framework for Implementation Research, and it assessed stewards' views on the development and implementation of antibiotic stewardship programs (ASPs) at their institutions We then examined differences in stewards' views by demographic factors., Results: Regardless of individual factors, stewards agreed that the ASP added value to their institution and was advantageous to patient care. Stewards also reported high levels of collegiality and self-efficacy. Stewards who had specialized training or those volunteered for the role were less likely to think that the ASP was implemented due to a mandate. Similarly volunteers and those with specialized training felt that they had authority in the antibiotic decisions made in their facility., Conclusions: Given the importance of ASPs, it may be beneficial for healthcare institutions to recruit and train individuals with a true interest in stewardship., (© The Author(s) 2021.)

Embedding research and evaluation into organizations is one way to generate "practice-based" evidence needed to accelerate implementation of evidence-based innovations within learning health systems. Organizations and researchers/evaluators vary greatly in how they structure and operationalize these collaborations. One key aspect is the degree of embeddedness: from low embeddedness where researchers/evaluators are located outside organizations (eg, outside evaluation consultants) to high embeddedness where researchers/evaluators are employed by organizations and thus more deeply involved in program evolution and operations. Pros and cons related to the degree of embeddedness (low vs high) must be balanced when developing these relationships. We reflect on this process within the context of an embedded, mixed-methods evaluation of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program. Considerations that must be balanced include: (a) low vs high alignment of goals; (b) low vs high involvement in strategic planning; (c) observing what is happening vs being integrally involved with programmatic activities; (d) reporting findings at the project's end vs providing iterative findings and recommendations that contribute to program evolution; and (e) adhering to predetermined aims vs adapting aims in response to evolving partner needs., Competing Interests: Authors have no conflicts to declare. All authors are employees of the United States Department of Veterans Affairs. No authors received compensation for preparation of this manuscript outside of their salaries., (Published 2021. This article is a U.S. Government work and is in the public domain in the USA. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.)

Background: While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach., Methods: A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of "new" MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates., Results: One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47)., Conclusions: Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE!, (© 2021. The Author(s).)

Background: Qualitative approaches, alone or in mixed methods, are prominent within implementation science. However, traditional qualitative approaches are resource intensive, which has led to the development of rapid qualitative approaches. Published rapid approaches are often inductive in nature and rely on transcripts of interviews. We describe a deductive rapid analysis approach using the Consolidated Framework for Implementation Research (CFIR) that uses notes and audio recordings. This paper compares our rapid versus traditional deductive CFIR approach., Methods: Semi-structured interviews were conducted for two cohorts of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE). The CFIR guided data collection and analysis. In cohort A, we used our traditional CFIR-based deductive analysis approach (directed content analysis), where two analysts completed independent in-depth manual coding of interview transcripts using qualitative software. In cohort B, we used our new rapid CFIR-based deductive analysis approach (directed content analysis), where the primary analyst wrote detailed notes during interviews and immediately "coded" notes into a MS Excel CFIR construct by facility matrix; a secondary analyst then listened to audio recordings and edited the matrix. We tracked time for our traditional and rapid deductive CFIR approaches using a spreadsheet and captured transcription costs from invoices. We retrospectively compared our approaches in terms of effectiveness and rigor., Results: Cohorts A and B were similar in terms of the amount of data collected. However, our rapid deductive CFIR approach required 409.5 analyst hours compared to 683 h during the traditional deductive CFIR approach. The rapid deductive approach eliminated $7250 in transcription costs. The facility-level analysis phase provided the greatest savings: 14 h/facility for the traditional analysis versus 3.92 h/facility for the rapid analysis. Data interpretation required the same number of hours for both approaches., Conclusion: Our rapid deductive CFIR approach was less time intensive and eliminated transcription costs, yet effective in meeting evaluation objectives and establishing rigor. Researchers should consider the following when employing our approach: (1) team expertise in the CFIR and qualitative methods, (2) level of detail needed to meet project aims, (3) mode of data to analyze, and (4) advantages and disadvantages of using the CFIR.

Background: Organizational culture, organizational climate, and implementation climate are key organizational constructs that influence the implementation of evidence-based practices. However, there has been little systematic investigation of the availability of psychometrically strong measures that can be used to assess these constructs in behavioral health. This systematic review identified and assessed the psychometric properties of measures of organizational culture, organizational climate, implementation climate, and related subconstructs as defined by the Consolidated Framework for Implementation Research (CFIR) and Ehrhart and colleagues., Methods: Data collection involved search string generation, title and abstract screening, full-text review, construct assignment, and citation searches for all known empirical uses. Data relevant to nine psychometric criteria from the Psychometric and Pragmatic Evidence Rating Scale (PAPERS) were extracted: internal consistency, convergent validity, discriminant validity, known-groups validity, predictive validity, concurrent validity, structural validity, responsiveness, and norms. Extracted data for each criterion were rated on a scale from -1 ("poor") to 4 ("excellent"), and each measure was assigned a total score (highest possible score = 36) that formed the basis for head-to-head comparisons of measures for each focal construct., Results: We identified full measures or relevant subscales of broader measures for organizational culture ( n  = 21), organizational climate ( n  = 36), implementation climate ( n  = 2), tension for change ( n  = 2), compatibility ( n  = 6), relative priority ( n  = 2), organizational incentives and rewards ( n  = 3), goals and feedback ( n  = 3), and learning climate ( n  = 2). Psychometric evidence was most frequently available for internal consistency and norms. Information about other psychometric properties was less available. Median ratings for psychometric properties across categories of measures ranged from "poor" to "good." There was limited evidence of responsiveness or predictive validity., Conclusion: While several promising measures were identified, the overall state of measurement related to these constructs is poor. To enhance understanding of how these constructs influence implementation research and practice, measures that are sensitive to change and predictive of key implementation and clinical outcomes are required. There is a need for further testing of the most promising measures, and ample opportunity to develop additional psychometrically strong measures of these important constructs., Plain Language Summary: Organizational culture, organizational climate, and implementation climate can play a critical role in facilitating or impeding the successful implementation and sustainment of evidence-based practices. Advancing our understanding of how these contextual factors independently or collectively influence implementation and clinical outcomes requires measures that are reliable and valid. Previous systematic reviews identified measures of organizational factors that influence implementation, but none focused explicitly on behavioral health; focused solely on organizational culture, organizational climate, and implementation climate; or assessed the evidence base of all known uses of a measure within a given area, such as behavioral health-focused implementation efforts. The purpose of this study was to identify and assess the psychometric properties of measures of organizational culture, organizational climate, implementation climate, and related subconstructs that have been used in behavioral health-focused implementation research. We identified 21 measures of organizational culture, 36 measures of organizational climate, 2 measures of implementation climate, 2 measures of tension for change, 6 measures of compatibility, 2 measures of relative priority, 3 measures of organizational incentives and rewards, 3 measures of goals and feedback, and 2 measures of learning climate. Some promising measures were identified; however, the overall state of measurement across these constructs is poor. This review highlights specific areas for improvement and suggests the need to rigorously evaluate existing measures and develop new measures., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Funding for this study came from the National Institute of Mental Health, awarded to Dr Cara C. Lewis as principal investigator. Dr Lewis is an author of this article and editor of the journal, Implementation Research and Practice. Due to this conflict, Dr Lewis was not involved in the editorial or review process for this article., (© The Author(s) 2021.)

Background: Although risk prediction has become an integral part of clinical practice guidelines for cardiovascular disease (CVD) prevention, multiple studies have shown that patients' risk still plays almost no role in clinical decision-making. Because little is known about why this is so, we sought to understand providers' views on the opportunities, barriers, and facilitators of incorporating risk prediction to guide their use of cardiovascular preventive medicines., Methods: We conducted semi-structured interviews with primary care providers (n = 33) at VA facilities in the Midwest. Facilities were chosen using a maximum variation approach according to their geography, size, proportion of MD to non-MD providers, and percentage of full-time providers. Providers included MD/DO physicians, physician assistants, nurse practitioners, and clinical pharmacists. Providers were asked about their reaction to a hypothetical situation in which the VA would introduce a risk prediction-based approach to CVD treatment. We conducted matrix and content analysis to identify providers' reactions to risk prediction, reasons for their reaction, and exemplar quotes., Results: Most providers were classified as Enthusiastic (n = 14) or Cautious Adopters (n = 15), with only a few Non-Adopters (n = 4). Providers described four key concerns toward adopting risk prediction. Their primary concern was that risk prediction is not always compatible with a "whole patient" approach to patient care. Other concerns included questions about the validity of the proposed risk prediction model, potential workflow burdens, and whether risk prediction adds value to existing clinical practice. Enthusiastic, Cautious, and Non-Adopters all expressed both doubts about and support for risk prediction categorizable in the above four key areas of concern., Conclusions: Providers were generally supportive of adopting risk prediction into CVD prevention, but many had misgivings, which included concerns about impact on workflow, validity of predictive models, the value of making this change, and possible negative effects on providers' ability to address the whole patient. These concerns have likely contributed to the slow introduction of risk prediction into clinical practice. These concerns will need to be addressed for risk prediction, and other approaches relying on "big data" including machine learning and artificial intelligence, to have a meaningful role in clinical practice.

Background: Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact., Methods: Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations., Results: The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion., Conclusions: Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients., Implications: Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment., (Published by Elsevier Inc.)

Background: Identifying feasible and effective implementation strategies remains a significant challenge. At present, there is a gap between the number of strategies prospectively included in implementation trials, typically four or fewer, and the number of strategies utilized retrospectively, often 20 or more. This gap points to the need for developing a better understanding of the range of implementation strategies that should be considered in implementation science and practice., Methods: This study elicited expert recommendations to identify which of 73 discrete implementation strategies were considered essential for implementing three mental health care high priority practices (HPPs) in the US Department of Veterans Affairs: depression outcome monitoring in primary care mental health ( n  = 20), prolonged exposure therapy for treating posttraumatic stress disorder ( n  = 22), and metabolic safety monitoring for patients taking antipsychotic medications ( n  = 20). Participants had expertise in implementation science, the specific HPP, or both. A highly structured recommendation process was used to obtain recommendations for each HPP., Results: Majority consensus was identified for 26 or more strategies as absolutely essential ; 53 or more strategies were identified as either likely essential or absolutely essential across the three HPPs., Conclusions: The large number of strategies identified as essential starkly contrasts with existing research that largely focuses on application of single strategies to support implementation. Systematic investigation and documentation of multi-strategy implementation initiatives is needed., Plain Language Summary: Most implementation studies focus on the impact of a relatively small number of discrete implementation strategies on the uptake of a practice. However, studies that systematically survey providers find that dozens or more discrete implementation strategies can be identified in the context of the implementation initiative. This study engaged experts in implementation science and clinical practice in a structured recommendation process to identify which of the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies were considered absolutely essential, likely essential, likely inessential, and absolutely inessential for each of the three distinct mental health care practices: depression outcome monitoring in primary care, prolonged exposure therapy for posttraumatic stress disorder, and metabolic safety monitoring for patients taking antipsychotic medications. The results highlight that experts consider a large number of strategies as absolutely or likely essential for supporting the implementation of mental health care practices. For example, 26 strategies were identified as absolutely essential for all three mental health care practices. Another 27 strategies were identified as either absolutely or likely essential across all three practices. This study points to the need for future studies to document the decision-making process an initiative undergoes to identify which strategies to include and exclude in an implementation effort. In particular, a structured approach to this documentation may be necessary to identify strategies that may be endogenous to a care setting and that may not be otherwise be identified as being "deliberately" used to support a practice or intervention., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions., Methods: We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017-2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success., Results: We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders' professional values, perception of meeting patients' needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused., Conclusions: Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.

Background: Measurement is a critical component for any field. Systematic reviews are a way to locate measures and uncover gaps in current measurement practices. The present study identified measures used in behavioral health settings that assessed all constructs within the Process domain and two constructs from the Inner setting domain as defined by the Consolidated Framework for Implementation Research (CFIR). While previous conceptual work has established the importance social networks and key stakeholders play throughout the implementation process, measurement studies have not focused on investigating the quality of how these activities are being carried out., Methods: The review occurred in three phases: Phase I, data collection included (1) search string generation, (2) title and abstract screening, (3) full text review, (4) mapping to CFIR-constructs, and (5) "cited-by" searches. Phase II, data extraction, consisted of coding information relevant to the nine psychometric properties included in the Psychometric And Pragmatic Rating Scale (PAPERS). In Phase III, data analysis was completed., Results: Measures were identified in only seven constructs: Structural characteristics ( n  = 13), Networks and communication ( n  = 29), Engaging ( n  = 1), Opinion leaders ( n  = 5), Champions ( n  = 5), Planning ( n  = 5), and Reflecting and evaluating ( n  = 5). No quantitative assessment measures of Formally appointed implementation leaders , External change agents , or Executing were identified. Internal consistency and norms were reported on most often, whereas no studies reported on discriminant validity or responsiveness. Not one measure in the sample reported all nine psychometric properties evaluated by the PAPERS. Scores in the identified sample of measures ranged from "-2" to "10" out of a total of "36.", Conclusions: Overall measures demonstrated minimal to adequate evidence and available psychometric information was limited. The majority were study specific, limiting their generalizability. Future work should focus on more rigorous measure development and testing of currently existing measures, while moving away from creating new, single use measures., Plain Language Summary: How we measure the processes and players involved for implementing evidence-based interventions is crucial to understanding what factors are helping or hurting the intervention's use in practice and how to take the intervention to scale. Unfortunately, measures of these factors-stakeholders, their networks and communication, and their implementation activities-have received little attention. This study sought to identify and evaluate the quality of these types of measures. Our review focused on collecting measures used for identifying influential staff members, known as opinion leaders and champions, and investigating how they plan, execute, engage, and evaluate the hard work of implementation. Upon identifying these measures, we collected all published information about their uses to evaluate the quality of their evidence with respect to their ability to produce consistent results across items within each use (i.e., reliable) and if they assess what they are intending to measure (i.e., valid). Our searches located over 40 measures deployed in behavioral health settings for evaluation. We observed a dearth of evidence for reliability and validity and when evidence existed the quality was low. These findings tell us that more measurement work is needed to better understand how to optimize players and processes for the purposes of successful implementation., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Introduction: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program developed and manages a framework for identification, replication, and diffusion of promising practices throughout the nation's largest integrated health care system. DoE identifies promising practices through a "Shark Tank" competition with winning bidders receiving external implementation facilitation. DoE further supports diffusion of successful practices across the VHA., Methods: This article presents results of a mixed methods implementation evaluation of DoE, focusing on program reach, program participation and decisions to adopt innovative practices, implementation processes, and practice sustainment. Data sources include practice adoption metrics, focus groups with bidders (two focus groups), observations of DoE events (seven events), surveys of stakeholders (five separate surveys), and semistructured interviews of facility directors, practice developers, implementation teams, and facilitators (133 participants)., Results: In the first four Shark Tank cohorts (2016-2018), 1,676 practices were submitted; 47 were designated Gold Status Practices (practices with facilitated implementation). Motivation for participation varied. Generally, staff led projects targeting problems they felt passionate about, facility directors focused on big-picture quality metrics and getting middle manager support, and frontline staff displayed variable motivation to implement new projects. Approximately half of facilitated implementation efforts were successful; barriers included insufficient infrastructure, staff, and resources. At the facility level, 73.3% of facilities originating or receiving facilitated implementation support have maintained the practice. VHA-wide, 834 decisions to adopt these practices were made., Conclusion: DoE has resulted in the identification of many candidate practices, promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across the VHA., (Published by Elsevier Inc.)

The use of reliable, valid measures in implementation practice will remain limited without pragmatic measures. Previous research identified the need for pragmatic measures, though the characteristic identification used only expert opinion and literature review. Our team completed four studies to develop a stakeholder-driven pragmatic rating criteria for implementation measures. We published Studies 1 (identifying dimensions of the pragmatic construct) and 2 (clarifying the internal structure) that engaged stakeholders-participants in mental health provider and implementation settings-to identify 17 terms/phrases across four categories: Useful, Compatible, Acceptable, and Easy. This paper presents Studies 3 and 4: a Delphi to ascertain stakeholder-prioritized dimensions within a mental health context, and a pilot study applying the rating criteria. Stakeholders (N = 26) participated in a Delphi and rated the relevance of 17 terms/phrases to the pragmatic construct. The investigator team further defined and shortened the list, which were piloted with 60 implementation measures. The Delphi confirmed the importance of all pragmatic criteria, but provided little guidance on relative importance. The investigators removed or combined terms/phrases to obtain 11 criteria. The 6-point rating system assigned to each criterion demonstrated sufficient variability across items. The grey literature did not add critical information. This work produced the first stakeholder-driven rating criteria to assess whether measures are pragmatic. The Psychometric and Pragmatic Evidence Rating Scale (PAPERS) combines the pragmatic criteria with psychometric rating criteria, from previous work. Use of PAPERS can inform development of implementation measures and to assess the quality of existing measures., (© Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams' quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation., Objectives: Develop a QI training program ("Learn. Engage. Act. Process." (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA)., Design: This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated., Participants: VHA facility-based MOVE! teams., Interventions: LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform., Main Measures: Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction., Key Results: Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81-89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work., Conclusions: LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.

Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2-4 subgroups based on splits of 1-3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact., Trial Registration: ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226., Competing Interests: All authors concur with this submission. This manuscript has not been submitted to another journal nor published elsewhere. Apart from Dr. Maciejewski, no authors have financial or commercial conflicts of interest. Dr. Maciejewski owns Amgen stock due to his spouse's employment., (© 2020 The Authors.)

Background: Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort., Methods: We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017-18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders ("champions") strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes., Results: We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success., Conclusions: Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

Background: Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone., Objective: The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching., Methods: Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation., Results: The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm., Conclusions: Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial's 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up., Trial Registration: ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293., International Registered Report Identifier (irrid): RR2-10.2196/12526., (©Laura J Damschroder, Lorraine R Buis, Felicia A McCant, Hyungjin Myra Kim, Richard Evans, Eugene Z Oddone, Lori A Bastian, Gwendolyn Hooks, Reema Kadri, Courtney White-Clark, Caroline R Richardson, Jennifer M Gierisch. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.08.2020.)

Objective: Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures., Methods: A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected., Results: We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%)., Conclusions: A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA. Obesity published by Wiley Periodicals, Inc. on behalf of The Obesity Society (TOS).)

Background: Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs., Methods: Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems., Results: We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success., Conclusions: The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate., (© The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Short-term health care costs following completion of health risk assessments and coaching programs in the VA have not been assessed., Objective: To compare VA health care expenditures among veterans who participated in a behavioral intervention trial that randomized patients to complete a HRA followed by health coaching (HRA + coaching) or to complete the HRA without coaching (HRA-alone)., Design: Four-hundred seventeen veterans at three Veterans Affairs (VA) Medical Centers or Clinics were randomized to HRA + coaching or HRA-alone. Veterans randomized to HRA-alone (n = 209) were encouraged to discuss HRA results with their primary care team, while veterans randomized to HRA + coaching (n = 208) received two brief telephone-delivered health coaching calls., Participants: We included 411 veterans with available cost data., Main Measures: Total VA health expenditures 6 months following trial enrollment were estimated using a generalized linear model with a gamma distribution and log link function. In exploratory analysis, model-based recursive partitioning was used to determine whether the intervention effect on short-term costs differed among any patient subgroups., Key Results: Most participants were male (85%); mean age was 56, and mean body mass index was 34. From the generalized linear model, 6-month estimated mean total VA expenditures were similar ($8665 for HRA + coaching vs $9900 for HRA-alone, p = 0.25). In exploratory subgroup analysis, among unemployed veterans with good sleep and fair or poor perceived health, mean observed expenditures in the HRA + coaching group were higher than in the HRA-alone group ($12,814 vs $7971). Among unemployed veterans with good sleep and good general health, mean observed expenditures in the HRA + coaching group were lower than in the HRA-alone group ($5082 vs $11,612)., Conclusions: Compared to completing and receiving HRA results, working with health coaches to set actionable health behavior change goals following HRA completion did not reduce short-term health expenditures., Trial Registration: Clinicaltrials.gov identifier: NCT01828567.

Implementation science has been recognized as a potential catalyst for health system reform, in part, because of its contribution of well-grounded conceptual theories, often encapsulated in frameworks. Well-designed frameworks provide a semantic structure, a common language by which to guide systematic approaches to studying implementation and testing interventions. An overview of the types and roles of theory in advancing implementation science is offered in this article. Resources for selecting appropriate frameworks are described along with illustrative examples. The case is made that well-developed theory is what enables knowledge to emerge out of seeming chaos and for translation of that knowledge to be widely and reliably implemented into routine practice so that health and well-being of patients is maximized by delivery of interventions that are rooted in that knowledge., (Copyright © 2019. Published by Elsevier B.V.)