Identifying core strategies and mechanisms for spreading a national medicines optimisation programme across England-a mixed-method study applying qualitative thematic analysis and Qualitative Comparative Analysis.

BACKGROUND: Achieving widespread adoption of innovations across health systems remains a challenge. Past efforts have focused on identifying and classifying strategies to actively support innovation spread (replicating an innovation across sites), but we lack an understanding about the mechanisms which such strategies draw on to deliver successful spread outcomes. There is also no established methodology to identify core strategies or mechanisms which could be replicated with fidelity in new contexts when spreading innovations. We aimed to understand which strategies and mechanisms are connected with successful spread using the case of a national medicines optimisation programme in England. METHODS: The study applied a comparative mixed-method case study approach. We compared spread activity in 15 Academic Health Science Networks (AHSN) in England, applied to one innovation case, Transfers of Care Around Medicines (TCAM). We followed two methodological steps: (1) qualitative thematic analysis of primary data collected from 18 interviews with AHSN staff members to identify the strategies and mechanisms and related contextual determinants and (2) Qualitative Comparative Analysis (QCA) combining secondary quantitative data on spread outcome and qualitative themes from step 1 to identify the core strategies and mechanisms. RESULTS: We identified six common spread strategy-mechanism constructs that AHSNs applied to spread the TCAM national spread programme: (1) the unique intermediary position of the AHSN as "honest broker" and local networking organisation, (2) the right capacity and position of the spread facilitator, (3) an intersectoral and integrated stakeholder engagement approach, (4) the dynamic marriage of the innovation with local health and care system needs and characteristics, (5) the generation of local evidence, and (6) the timing of TCAM. The QCA resulted in the core strategy/mechanism of a timely start into the national spread programme in combination with the employment of a local, senior pharmacist as an AHSN spread facilitator. CONCLUSIONS: By qualitatively comparing experiences of spreading one innovation across different contexts, we identified common strategies, causal mechanisms, and contextual determinants. The QCA identified one core combination of two strategies/mechanisms. The identification of core strategies/mechanisms and common pre-conditional and mediating contextual determinants of a specific innovation offers spread facilitators and implementers a priority list for tailoring spread activities.

Academic health science networks' experiences with rapid implementation practice during the COVID-19 pandemic in England.

The COVID-19 pandemic offered a "natural laboratory" to learn about rapid implementation of health and social care innovations in an altered implementation context. Our aim was to explore implementation practice of Academic Health Science Networks (AHSN) in the English National Health System during the first wave of the COVID-19 pandemic through a rapid implementation lens. We organized three 90-min, online, semi-structured focus groups with 26 operational and senior managerial staff from 14 AHSNs in June-July 2020. Participants were recruited purposefully and on a voluntary basis. Participants presented a case study about their approaches to implementing innovations between March-June 2020 and discussed their experiences and lessons learned. The focus groups were audio-recorded and transcribed verbatim. Transcripts and other documents were analyzed using qualitative thematic analysis following a combination of grounded theory and framework analysis approach. AHSNs increased the pace of their implementation work to support the response to the COVID-19 pandemic. The disruptive event changed the implementation context which enabled rapid implementation through an urgency for change, the need to adhere to social distancing rules, new enabling governance structures, and stakeholders' reduced risk averseness toward change. AHSNs achieved rapid implementation through: (1) An agile and adaptive implementation approach; (2) Accelerating existing innovations and building on existing relationships/networks; (3) Remote stakeholder engagement; and (4) Ensuring quality, safety, rigor and sustainability, and generating new evidence through rapid evaluations. AHSNs aimed at sustaining implementation pace and efficiency after the acute phase of the pandemic mainly through remote stakeholder engagement and flexibility of implementation strategies.

"A non-person to the rest of the world": experiences of social isolation amongst severely impaired people with multiple sclerosis.

Purpose: To gain insight into the experiences of, and potential solutions to, social isolation amongst severely impaired people with multiple sclerosis.Methods: A phenomenological research approach using face-to-face, in-depth semi-structured, audio-recorded interviews. Data were transcribed and analyzed thematically.Results: Sixteen severely impaired people with multiple sclerosis were interviewed (Expanded Disability Status Scale >6.5); aged 38-72 years, nine female, time since diagnosis ranged 3-30 years). Four key themes were generated in line with the study objectives, each with further sub-themes. The themes were (1) Definitions of isolation (2) Causes of isolation (3) Impact of isolation, and (4) Potential eases of isolation.Conclusions: Data portrayed social isolation as complex and multi-factorial in its definitions, its causes, and its impact. Isolation is not just about being lonely or left on one's own, but represents a spiral of impacts. Physical deterioration can lead to reduced choice and control regarding access to, and interaction with others and society, affecting personal identity. Sometimes this leads to further self-isolation. Personalised psychosocial support, with improved ease of access, focused on helping people with severe multiple sclerosis regain a sense of self and their place in the world may ease social isolation.Implications for rehabilitationPeople with severe multiple sclerosis can experience a sense of powerlessness, a lack of choice and control over daily life, leading to changes in self-identity and social isolation.Peoples' experiences are very personal, and any approach to help deal with social isolation needs to be based in considering how to think positively about how life can be lived and how to make that work.Multiple sclerosis support groups should not be assumed to alleviate feelings of social isolation.Interventions should focus on personalized psychosocial input aimed at helping the person with multiple sclerosis regain a sense of self and their place in the world.

Involving community pharmacists in transfer of care from hospital: Indications of reduced 30-day hospital readmission rates for patients in Cornwall.

OBJECTIVES: The purpose of this study was to determine any benefit from a discharge transfer of care service from hospital to community pharmacy. METHOD: A cross-sectional cohort design was used to compare actioned and non-actioned transfers of care. KEY FINDINGS: Of the 1130 transfers of care referrals to pharmacies in 2017, 365 patients received an actioned community pharmacy service after discharge. The 30-day readmission rate was 8.5% (31/365) in those who received an actioned community pharmacist service compared to 23.3% (178/765) in those who did not. Odds ratio for readmission at 30 days was 3.26 (95% CI 2.04 to 4.59, P < 0.0001), significantly higher in those not receiving an actioned transfer of care service. CONCLUSION: Involving community pharmacy at patient discharge appears to contribute to lower rates of readmission.

The DiReCT study - improving recruitment into clinical trials: a mixed methods study investigating the ethical acceptability, feasibility and recruitment yield of the cohort multiple randomised controlled trials design.

BACKGROUND: The 'cohort multiple Randomised Controlled Trial' (cmRCT) design has been proposed as a potential solution to poor recruitment into clinical trials. The design randomly selects participants eligible for experimental treatments from a pre-enrolled cohort of patients, recruiting participants to multiple trials from a single cohort. Controls remain unaware of their participation in specific trials. METHODS: We undertook a mixed methods study to determine the ethical acceptability, the proportion of patients in a routine service consenting to cohort participation, the proportion of these who would consent to being hypothetically randomly selected to receive new treatments, and the views of clinicians on the acceptability of the design. We submitted our cmRCT design for ethical review and recruited participants from people with anxiety and depression attending a community mental health service of twenty-one clinicians. We recorded the proportion of patients who were offered participation in the DiReCT study and the proportion that consented to researcher contact, medical record sharing, and who accepted to be randomly allocated to active treatment procedures in future hypothetical unspecified clinical trials. We used a thematic framework analysis to analyse clinician interviews. RESULTS: We obtained a favourable ethical opinion from the UK Health Research Authority. Clinicians approached 131/752 (17%) potentially eligible participants for consent. Of these 131, 84 (64%) initially consented to be contacted by a researcher and all but one consented to being randomised into future trials. We confirmed consent for 71 (54%) of participants approached by clinicians, of whom 69 (53%) consented to being randomised into hypothetical future trials, 9% (69/752) of all potentially eligible patients. The interviewed clinicians described issues impacting on their ability to recruit participants in terms of clinical concerns for patient wellbeing, work pressure, their views of both general research and the specific DiReCT study, and how they viewed patients' responses to being offered participation in the study. CONCLUSIONS: The cmRCT system offers the potential to improve the recruitment into clinical trials and is acceptable ethically and to many patients. Overcoming the multiple factors driving the difficulties clinicians experience in patient recruitment is likely to require the application of significant implementation science-informed effort.