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Background It is challenging to conduct and quickly disseminate findings from in-depth qualitative analyses, which can impede timely implementation of interventions because of its time-consuming methods. To better understand tradeoffs between the need for actionable results and scientific rigor, we present our method for conducting a framework-guided rapid analysis (RA) and a comparison of these findings to an in-depth analysis of interview transcripts. Methods Set within the context of an evaluation of a successful academic detailing (AD) program for opioid prescribing in the Veterans Health Administration, we developed interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and interviewed 10 academic detailers (clinical pharmacists) and 20 primary care providers to elicit detail about successful features of the program. For the RA, verbatim transcripts were summarized using a structured template (based on CFIR); summaries were subsequently consolidated into matrices by participant type to identify aspects of the program that worked well and ways to facilitate implementation elsewhere. For comparison purposes, we later conducted an in-depth analysis of the transcripts. We described our RA approach and qualitatively compared the RA and deductive in-depth analysis with respect to consistency of themes and resource intensity. Results Integrating the CFIR throughout the RA and in-depth analysis was helpful for providing structure and consistency across both analyses. Findings from the two analyses were consistent. The most frequently coded constructs from the in-depth analysis aligned well with themes from the RA, and the latter methods were sufficient and appropriate for addressing the primary evaluation goals. Our approach to RA was less resource-intensive than the in-depth analysis, allowing for timely dissemination of findings to our operations partner that could be integrated into ongoing implementation. Conclusions In-depth analyses can be resource-intensive. If consistent with project needs (e.g., to quickly produce information to inform ongoing implementation or to comply with a policy mandate), it is reasonable to consider using RA, especially when faced with resource constraints. Our RA provided valid findings in a short timeframe, enabling identification of actionable suggestions for our operations partner.

Background The use of rapid qualitative methods has increased substantially over the past decade in quality improvement and health services research. These methods have gained traction in implementation research and practice, wherein real-time adjustments are often made to optimize processes and outcomes. This brisk increase begs the questions: what does rigor entail in projects that use rapid qualitative analysis (RQA)? How do we define a pragmatic framework to help research teams design and conduct rigorous and valid rapid qualitative projects? How can authors articulate rigor in their methods descriptions? Lastly, how can reviewers evaluate the rigor of rapid qualitative projects?. Methods A team of seven interdisciplinary qualitative methods experts developed a framework for ensuring rigor and validity in RQA and methods suitable for this analytic approach. We conducted a qualitative evidence synthesis to identify gaps in the literature and then drew upon literature, standard procedures within our teams, and a repository of rapid qualitative training materials to create a planning and reporting framework. We iteratively refined this framework through 11 group working meetings (60-90 minutes each) over the course of one year and invited feedback on items to ensure their completeness, clarity, and comprehensibility. Results The Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA) framework is organized progressively across phases from design to dissemination, as follows: 1) rigorous design (rationale and staffing), 2) semi-structured data collection (pilot and planning), 3) RQA: summary template development (accuracy and calibration), 4) RQA: matrix analysis (matrices), and 5) rapid qualitative data synthesis. Eighteen recommendations across these sections specify best practices for rigor and validity. Conclusions Rapid qualitative methods play a central role in implementation evaluations, with the potential to yield prompt information and insights about context, processes, and relationships. However, guidance on how to assess rigor is nascent. The PARRQA framework enhances the literature by offering criteria to ensure appropriate planning for and assessment of rigor in projects that involve RQA. This framework provides a consensus-based resource to support high-level qualitative methodological rigor in implementation science.

In 2016, the US Department of Veterans Affairs (VA) implemented a national initiative to distribute video-enabled tablets and peripheral devices, such as blood pressure monitors and weighing scales, to patients facing geographic, clinical, or socioeconomic challenges. Such patients could potentially benefit from health monitoring in conjunction with video-based care, as peripheral devices offer opportunities to enrich care received during a video visit and support tracking of health-related data collected outside of clinical care, or patient-generated health data. However, little is known about experiences with the devices and how they could support improved access to care. We explored patients' experiences with VA-issued peripheral devices and their impact on video-based care and health monitoring outside of clinical visits. We conducted in-depth semistructured interviews among patients who received VA-issued tablets and peripheral devices between 2023 and 2024. Purposive sampling was used to gather views based on gender, age, race or ethnicity, and rurality. Interviews were transcribed and analyzed using rapid qualitative analysis, guided by the Unified Theory of Acceptance and Use of Technology. Among 25 patients, most received a blood pressure monitor (21/25, 84%), a weight scale (14/25, 56%), and/or a pulse oximetry device (12/25, 48%). The majority reported using their peripheral devices (23/25, 92%) and tablets (19/25, 76%) to monitor their vital signs and attend video visits. Qualitative analysis yielded ten themes reflecting experiences and impacts of the devices, organized by the Unified Theory of Acceptance and Use of Technology constructs: \"effort expectancy\" consisted of (1) familiar and easy to use devices and (2) challenges of Bluetooth pairing and measurement; \"performance expectancy\" consisted of (3) integration with video visits, (4) health monitoring for peace of mind, (5) perceptions of improved vital signs and lifestyle behaviors, (6) removing obstacles to in-person care, and (7) desiring an overall picture of health; \"social influence\" consisted of (8) fostering care team connections and (9) promoting awareness of tablets and peripheral devices; and \"facilitating conditions\" consisted of (10) supportive help desk infrastructure. Overall, patients described using peripheral devices during virtual visits by syncing data to the tablet for real-time access by their care team. They also reported manually tracking and sharing patient-generated health data with their care team. Despite some challenges with Bluetooth pairing, patients found the devices easy to use and contributed to improved health and motivation. Devices also reduced logistical burdens of in-person visits, especially for those with limited mobility, visual impairments, mental health needs, or transportation barriers. Patients perceive that peripheral devices can enhance video-based care and support health care access and chronic disease management. Patients reported benefits to health, behavior, and communication with care teams. To maximize the impact, program enhancements should prioritize device interoperability, accessible training, and expanded outreach.

Patient messaging technologies offer treatment information and recommendations through web-based platforms, patient portals, mobile apps, and SMS text messaging. Many of these technologies have started to incorporate messages that are crafted by artificial intelligence (AI). Such tools are most effective when constructed with theoretical grounding and iterative input from end users. Thus, we outline a human-centered design approach for developing patient messaging content that aligns with self-determination theory (SDT), a widely used framework that has shown positive impacts on health behavior change. We illustrate our approach step-by-step for the development of messages that promote evidence-based treatment opportunities for patients with chronic pain. Messages were initially developed by subject matter experts and refined using SDT constructs (autonomy, competence, and relatedness) and motivation and behavior change techniques. Using a rapid prototyping approach, we sequentially met with 3 patient engagement boards to elicit feedback on message prototypes and enhance their content. We synthesized and aligned disparate feedback across boards with SDT and motivation and behavior change techniques. Drawing upon the input from the engagement boards, existing co-design approaches, and the field of human-centered AI, we recommend strategies to collaborate with patient partners to enhance the readability and clarity of messaging content. Recommended strategies include (1) involve engagement boards early in messaging framing and modality selection, (2) represent diverse perspectives when refining messages, (3) acknowledge and set expectations to integrate unique experiences and views, (4) prioritize message tailoring for the population of interest, (5) incorporate continual feedback mechanisms, and (6) keep the human interaction in patient-facing messages. By illuminating the process of developing message content that aligns with SDT constructs and providing guidance for iterative patient engagement and practical prototyping, we hope this tutorial can be used to enhance patient messaging content and improve uptake of evidence-based treatments. Our approach and recommendations can also guide multidisciplinary research and design teams to build patient-centered health messages. This tutorial has special consideration for future AI-guided messaging interventions, as patients are typically not involved in message content development or framing, but early engagement can potentially mitigate known AI concerns related to privacy, transparency, and fairness. As technologies and patient populations change over time, linking continual end user input with theoretical grounding plays a key role in simplifying complex medical information and promoting understanding of treatment opportunities that can ultimately improve health outcomes.

1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

IntroductionVulnerable populations face significant challenges in navigating the care continuum, ranging from diagnosis of illness to linkage and retention in healthcare. Understanding how best to move individuals within these vulnerable populations across the care continuum is critical to improving their health. A large body of literature has focused on evaluation of implementation of various health-focused interventions in this population. However, we do not fully understand the unique challenges to implementing healthcare interventions for vulnerable populations. This study aims to examine the literature describing implementation of health service interventions among vulnerable populations to identify how implementations using the Consolidated Framework for Implementation Research are adapted. Findings from this review will be useful to implementation scientists to identify gaps in evidence and for adapting similar interventions in unique settings.Methods and analysisThis study protocol outlines a scoping review of the peer-reviewed and grey literature, using established approaches delineated in Arksey and O'Malley’s scoping review framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. Search strategies will be developed and refined by a medical librarian in collaboration with the research team. Searches will be conducted in electronic databases (CINAHL, Cochrane, PsychINFO, PubMed, Social Services Abstracts, Web of Science, Google and Google Scholar) and limited to studies published between 1 August 2009 and 1 June 2020. Additionally, hand searches will be conducted in three relevant journals—Implementation Science, Systematic Reviews and BMJ Open. English-language studies and reports meeting inclusion criteria will be screened independently by two reviewers and the final list will be abstracted and charted in duplicate.Ethics and disseminationThis is a review of the literature; ethics approval is not indicated. We will disseminate findings from this study in peer-reviewed journals as well as presentations to relevant stakeholders and conferences.

Background Rigorous implementation evaluations are needed to understand factors that influence implementation and sustainability of evidence-based interventions across contexts. In this study, we conducted a longitudinal, multi-methods, multi-site evaluation guided by the Dynamic Sustainability Framework (DSF). This evaluation focused on implementation of the Homeless Overdose Prevention—Expansion (HOPE), an opioid overdose education and naloxone distribution (OEND) trial in a permanent supportive housing program in the Veterans Health Administration (VA). Methods We used a multi-methods study design comprised of qualitative interviews and completion of a three-item survey. Semi-structured interviews were completed with Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) staff, site leaders, and site prescribers at four VA healthcare systems in the Western United States. Interviews were conducted at three timepoints: pre-implementation, implementation, and sustainment. Site staff also completed the Provider REport of Sustainment Scale (PRESS) during sustainment to provide more context for our interpretation of results. We analyzed interview data using rapid directed content analysis guided by DSF constructs and analyzed PRESS using descriptive statistics. Results We conducted 96 interviews with 67 unique individuals. Six determinants influenced the reciprocal fit of the intervention, practice setting, and ecological system across our study: (1) OEND for unstably housed veterans; (2) Staffing shortages and competing demands; (3) Training-related concerns; (4) Supervisor and leadership buy-in at site; (5) Social workers’ scope of practice; and (6) Cultural climate and saliency of OEND initiatives. Both planned and unplanned implementation strategies were optimized by different actors (i.e., the implementation team, target practitioners) in response to evolving determinants at all three DSF levels to maintain overall fit. Approaches taken to optimize fit depended on longitudinal data collection and evaluation of determinants at each phase. Conclusions Our approach is a theoretically driven example of capturing important determinants of implementation and sustainment of OEND in a high-risk setting. Despite the uniqueness of our study setting, our approach is generalizable and has the potential to promote sustainability of other public health interventions.

Background Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers’ perceptions about MOUD over the first year of implementation. Methods Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach. Results Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents’ ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time. Conclusions Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers’ and clinical leaders’ perceptions of MOUD over time. Strategies that improve leaders’ prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.

Background Evidence-based practices (EBPs) are frequently adapted in response to the dynamic contexts in which they are implemented. Adaptation is defined as the degree to which an EBP is altered to fit the setting or to improve fit to local context and can be planned or unplanned. Although adaptations are common and necessary to maximizing the marginal impact of EBPs, little attention has been given to the economic consequences and how adaptations affect marginal costs. Discussion In assessing the economic consequences of adaptation, one should consider its impact on core components, the planned adaptive periphery, and the unplanned adaptive periphery. Guided by implementation science frameworks, we examine how various economic evaluation approaches accommodate the influence of adaptations and discuss the pros and cons of these approaches. Using the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME), mixed methods can elucidate the economic reasons driving the adaptations. Micro-costing approaches are applied in research that integrates the adaptation of EBPs at the planning stage using innovative, adaptive study designs. In contrast, evaluation of unplanned adaptation is subject to confounding and requires sensitivity analysis to address unobservable measures and other uncertainties. A case study is presented using the RE-AIM framework to illustrate the costing of adaptations. In addition to empirical approaches to evaluating adaptation, simulation modeling approaches can be used to overcome limited follow-up in implementation studies. Conclusions As implementation science evolves to improve our understanding of the mechanisms and implications of adaptations, it is increasingly important to understand the economic implications of such adaptations, in addition to their impact on clinical effectiveness. Therefore, explicit consideration is warranted of how costs can be evaluated as outcomes of adaptations to the delivery of EBPs.

Background Dissemination of evidence-based practices that can reduce morbidity and mortality is important to combat the growing opioid overdose crisis in the USA. Research and expert consensus support reducing high-dose opioid therapy, avoiding risky opioid-benzodiazepine combination therapy, and promoting multi-modal, collaborative models of pain care. Collaborative care interventions that support primary care providers have been effective in medication tapering. We developed a patient-centered Primary Care-Integrated Pain Support (PIPS) collaborative care clinical program based on effective components of previous collaborative care interventions. Implementation facilitation, a multi-faceted and dynamic strategy involving the provision of interactive problem-solving and support during implementation of a new program, is used to support key organizational staff throughout PIPS implementation. The primary aim of this study is to evaluate the effectiveness of the implementation facilitation strategy for implementing and sustaining PIPS in the Veterans Health Administration (VHA). The secondary aim is to examine the effect of the program on key patient-level clinical outcomes—transitioning to safer regimens and enhancing access to complementary and integrative health treatments. The tertiary aim is to determine the categorical costs and ultimate budget impact of PIPS implementation. Methods This multi-site study employs an interrupted time series, hybrid type III design to evaluate the effectiveness of implementation facilitation for a collaborative care clinical program—PIPS—in primary care clinics in three geographically diverse VHA health care systems (sites). Participants include pharmacists and allied staff involved in the delivery of clinical pain management services as well as patients. Eligible patients are prescribed either an outpatient opioid prescription greater than or equal to 90 mg morphine equivalent daily dose or a combination opioid-benzodiazepine regimen. They must also have an upcoming appointment in primary care. The Consolidated Framework for Implementation Research will guide the mixed methods work across the formative evaluation phases and informs the selection of activities included in implementation facilitation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of PIPS. Discussion This implementation study will provide important insight into the effectiveness of implementation facilitation to enhance uptake of a collaborative care program in primary care, which targets unsafe opioid prescribing practices.