A Cost Analysis of Rethink the Strip: De-implementing a Low-value Practice in Primary Care.

BACKGROUND: Routine self-monitoring of blood glucose is a low-value practice that provides limited benefit for patients with non-insulin-treated type 2 diabetes mellitus. OBJECTIVES: We estimated the costs of Rethink the Strip (RTS), a multistrategy approach to the de-implementation of self-monitoring of blood glucose in primary care. RESEARCH DESIGN: RTS was conducted among 20 primary care clinics in North Carolina. We estimated the non-site-based and site-based costs of the 5 RTS strategies (practice facilitation, audit and feedback, provider champions, educational meetings, and educational materials) from the analytic perspective of an integrated health care system for 12 and 27-month time horizons. Material costs were tracked through project records, and personnel costs were assessed using activity-based costing. We used nationally based wage estimates. RESULTS: Total RTS costs equaled $68,941 for 12 months. Specifically, non-site-based costs comprised $16,560. Most non-site-based costs ($11,822) were from the foundational programming and coding updates to the electronic health record data to develop the audit and feedback reports. The non-site-based costs of educational meetings, practice facilitation, and educational materials were substantially lower, ranging between ~$400 and $1000. Total 12-month site-based costs equaled $2569 for a single clinic (or $52,381 for 20 clinics). Educational meetings were the most expensive strategy, averaging $1401 per clinic. The site-based costs for the 4 other implementation strategies were markedly lower, ranging between $51 for educational materials and $555 for practice facilitation per clinic. CONCLUSIONS: This study provides detailed cost information for implementation strategies used to support evidence-based programs in primary care clinics.

Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study.

Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.

Grounding implementation science in health equity for cancer prevention and control.

BACKGROUND: The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions. DISCUSSION: In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Extending analytic methods for economic evaluation in implementation science.

BACKGROUND: Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation. MAIN BODY: We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the "boundaries" of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection-particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs. CONCLUSION: Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative.

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

The Cancer Prevention and Control Research Network: Accelerating the implementation of evidence-based cancer prevention and control interventions.

This editorial provides a high level overview of the articles included in this supplement.

Tapping Into Multiple Data "Springs" to Strengthen Policy Streams: A Guide to the Types of Data Needed to Formulate Local Retail Tobacco Control Policy.

In 2015, the tobacco industry spent $8.24 billion to market tobacco products in convenience stores, supermarkets, pharmacies, and other retail or point-of-sale settings. Community tobacco control partnerships have numerous evidence-based policies (eg, tobacco retailer licensing and compliance, tobacco-free-school buffer zones, eliminating price discounts) to counter point-of-sale tobacco marketing. However, deciding which point-of-sale policies to implement - and when and in what order to implement them - is challenging. The objective of this article was to describe tools and other resources that local-level tobacco use prevention and control leaders can use to assemble the data they need to formulate point-of-sale tobacco policies that fit the needs of their communities, have potential for public health impact, and are feasible in the local policy environment. We were guided by Kingdon's theory of policy change, which contends that windows of policy opportunity open when 3 streams align: a clear problem, a solution to the problem, and the political will to work for change. Community partnerships can draw on 7 data "springs" to activate Kingdon's streams: 1) epidemiologic and surveillance data, 2) macro retail environment data, 3) micro retail environment data, 4) the current policy context, 5) local legal feasibility of policy options, 6) the potential for public health impact, and 7) political will.

Coaching primary care clinics for HPV vaccination quality improvement: Comparing in-person and webinar implementation.

State health departments commonly use quality improvement coaching as an implementation strategy for improving low human papillomavirus (HPV) vaccination coverage, but such coaching can be resource intensive. To explore opportunities for improving efficiency, we compared in-person and webinar delivery of coaching sessions on implementation outcomes, including reach, acceptability, and delivery cost. In 2015, we randomly assigned 148 high-volume primary care clinics in Illinois, Michigan, and Washington State to receive either in-person or webinar coaching. Coaching sessions lasted about 1 hr and used our Immunization Report Card to facilitate assessment and feedback. Clinics served over 213,000 patients ages 11-17. We used provider surveys and delivery cost assessment to collect implementation data. This report is focused exclusively on the implementation aspects of the intervention. More providers attended in-person than webinar coaching sessions (mean 9 vs. 5 providers per clinic, respectively, p = .004). More providers shared the Immunization Report Card at clinic staff meetings in the in-person than webinar arm (49% vs. 20%; p = .029). In both arms, providers' belief that their clinics' HPV vaccination coverage was too low increased, as did their self-efficacy to help their clinics improve (p < .05). Providers rated coaching sessions in the two arms equally highly on acceptability. Delivery cost per clinic was $733 for in-person coaching versus $461 for webinar coaching. In-person and webinar coaching were well received and yielded improvements in provider beliefs and self-efficacy regarding HPV vaccine quality improvement. In summary, in-person coaching cost more than webinar coaching per clinic reached, but reached more providers. Further implementation research is needed to understand how and for whom webinar coaching may be appropriate.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers.

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

A Feasibility Study of Supply and Demand for Diabetes Prevention Programs in North Carolina.

INTRODUCTION: Diabetes Prevention Programs (DPPs) have shown that healthy eating and moderate physical activity are effective ways of delaying and preventing type 2 diabetes in people with impaired glucose tolerance. We assessed willingness to pay for DPPs from the perspective of potential recipients and the cost of providing these programs from the perspective of community health centers and local health departments in North Carolina. METHODS: We used contingent valuation to determine how much potential recipients would be willing to pay to participate in DPPs under 3 different models: delivered by registered professionals (traditional model), by community health workers, or online. By using information on the minimum reimbursement rate at which public health agencies would be prepared to provide the 3 models, we estimated the marginal costs per person of supplying the programs. Matching supply and demand, we estimated the degree of cost sharing between recipients and providers. RESULTS: Potential program recipients (n = 99) were willing to pay more for programs led by registered professionals than by community health workers, and they preferred face-to-face contact to an online format. Socioeconomic status (measured by education and employment) and age played the biggest roles in determining willingness to pay. Leaders of public health agencies (n = 27) reported up to a 40% difference in the cost of providing the DPP, depending on the delivery model. CONCLUSION: By using willingness to pay to understand demand for DPPs and computing the provider's marginal cost of providing these services, we can estimate cost sharing and market coverage of these services and thus compare the viability of alternate approaches to scaling up and sustaining DPPs with available resources.

Implementation strategies to promote community-engaged efforts to counter tobacco marketing at the point of sale.

The US tobacco industry spends $8.2 billion annually on marketing at the point of sale (POS), a practice known to increase tobacco use. Evidence-based policy interventions (EBPIs) are available to reduce exposure to POS marketing, and nationwide, states are funding community-based tobacco control partnerships to promote local enactment of these EBPIs. Little is known, however, about what implementation strategies best support community partnerships' success enacting EBPI. Guided by Kingdon's theory of policy change, Counter Tools provides tools, training, and other implementation strategies to support community partnerships' performance of five core policy change processes: document local problem, formulate policy solutions, engage partners, raise awareness of problems and solutions, and persuade decision makers to enact new policy. We assessed Counter Tools' impact at 1 year on (1) partnership coordinators' self-efficacy, (2) partnerships' performance of core policy change processes, (3) community progress toward EBPI enactment, and (4) salient contextual factors. Counter Tools provided implementation strategies to 30 partnerships. Data on self-efficacy were collected using a pre-post survey. Structured interviews assessed performance of core policy change processes. Data also were collected on progress toward EBPI enactment and contextual factors. Analysis included descriptive and bivariate statistics and content analysis. Following 1-year exposure to implementation strategies, coordinators' self-efficacy increased significantly. Partnerships completed the greatest proportion of activities within the "engage partners" and "document local problem" core processes. Communities made only limited progress toward policy enactment. Findings can inform delivery of implementation strategies and tests of their effects on community-level efforts to enact EBPIs.

Developing a Tool to Assess the Capacity of Out-of-School Time Program Providers to Implement Policy, Systems, and Environmental Change.

BACKGROUND: Little is known about public health practitioners' capacity to change policies, systems, or environments (PSEs), in part due to the absence of measures. To address this need, we partnered with the Alliance for a Healthier Generation (Alliance) to develop and test a theory-derived measure of the capacity of out-of-school time program providers to improve students' level of nutrition and physical activity through changes in PSEs. COMMUNITY CONTEXT: The measure was developed and tested through an engaged partnership with staff working on the Alliance's Healthy Out-of-School Time (HOST) Initiative. In total, approximately 2,000 sites nationwide are engaged in the HOST Initiative, which serves predominantly high-need children and youths. METHODS: We partnered with the Alliance to conduct formative work that would help develop a survey that assessed attitudes/beliefs, social norms, external resources/supports, and self-efficacy. The survey was administered to providers of out-of-school time programs who were implementing the Alliance's HOST Initiative. OUTCOME: Survey respondents were 185 out-of-school time program providers (53% response rate). Exploratory factor analysis yielded a 4-factor model that explained 44.7% of the variance. Factors pertained to perceptions of social norms (6 items) and self-efficacy to build support and engage a team (4 items) and create (5 items) and implement (3 items) an action plan. INTERPRETATION: We report initial development and factor analysis of a tool that the Alliance can use to assess the capacity of after-school time program providers, which is critical to targeting capacity-building interventions and assessing their effectiveness. Study findings also will inform the development of measures to assess individual capacity to plan and implement other PSE interventions.

Synthesizing Marketing, Community Engagement, and Systems Science Approaches for Advancing Translational Research.

The adoption and implementation of evidence-based interventions (EBIs) are the goals of translational research; however, potential end-users' perceptions of an EBI value have contributed to low rates of adoption. In this article, we describe our application of emerging dissemination and implementation science theoretical perspectives, community engagement, and systems science principles to develop a novel EBI dissemination approach. Using consumer-driven, graphics-rich simulation, the approach demonstrates predicted implementation effects on health and employment outcomes for socioeconomically disadvantaged women at the local level and is designed to increase adoption interest of county program managers accountable for improving these outcomes in their communities.

Assessment of training and technical assistance needs of Colorectal Cancer Control Program Grantees in the U.S.

BACKGROUND: Practitioners often require training and technical assistance to build their capacity to select, adapt, and implement evidence-based interventions (EBIs). The CDC Colorectal Cancer Control Program (CRCCP) aims to promote CRC screening to increase population-level screening. This study identified the training and technical assistance (TA) needs and preferences for training related to the implementation of EBIs among CRCCP grantees. METHODS: Twenty-nine CRCCP grantees completed an online survey about their screening activities, training and technical assistance in 2012. They rated desire for training on various evidence-based strategies to increase cancer screening, evidence-based competencies, and program management topics. They also reported preferences for training formats and facilitators and barriers to trainings. RESULTS: Many CRCCP grantees expressed the need for training with regards to specific EBIs, especially system-level and provider-directed EBIs to promote CRC screening. Grantees rated these EBIs as more difficult to implement than client-oriented EBIs. Grantees also reported a moderate need for training regarding finding EBIs, assessing organizational capacity, implementing selected EBIs, and conducting process and outcome evaluations. Other desired training topics reported with higher frequency were partnership development and data collection/evaluation. Grantees preferred training formats that were interactive such as on-site trainings, webinars or expert consultants. CONCLUSIONS: Public health organizations need greater supports for adopting evidence-based interventions, working with organizational-level change, partnership development and data management. Future capacity building efforts for the adoption of EBIs should focus on systems or provider level interventions and key processes for health promotion and should be delivered in a variety of ways to assist local organizations in cancer prevention and control.

Capacity building for evidence-based decision making in local health departments: scaling up an effective training approach.

BACKGROUND: There are few studies describing how to scale up effective capacity-building approaches for public health practitioners. This study tested local-level evidence-based decision making (EBDM) capacity-building efforts in four U.S. states (Michigan, North Carolina, Ohio, and Washington) with a quasi-experimental design. METHODS: Partners within the four states delivered a previously established Evidence-Based Public Health (EBPH) training curriculum to local health department (LHD) staff. They worked with the research team to modify the curriculum with local data and examples while remaining attentive to course fidelity. Pre- and post-assessments of course participants (n=82) and an external control group (n=214) measured importance, availability (i.e., how available a skill is when needed, either within the skillset of the respondent or among others in the agency), and gaps in ten EBDM competencies. Simple and multiple linear regression models assessed the differences between pre- and post-assessment scores. Course participants also assessed the impact of the course on their work. RESULTS: Course participants reported greater increases in the availability, and decreases in the gaps, in EBDM competencies at post-test, relative to the control group. In adjusted models, significant differences (p<0.05) were found in 'action planning,' 'evaluation design,' 'communicating research to policymakers,' 'quantifying issues (using descriptive epidemiology),' and 'economic evaluation.' Nearly 45% of participants indicated that EBDM increased within their agency since the training. Course benefits included becoming better leaders and making scientifically informed decisions. CONCLUSIONS: This study demonstrates the potential for improving EBDM capacity among LHD practitioners using a train-the-trainer approach involving diverse partners. This approach allowed for local tailoring of strategies and extended the reach of the EBPH course.

Pricing health behavior interventions to promote adoption: lessons from the marketing and business literature.

The relatively high cost of delivering many public health interventions limits their potential for broad public impact by reducing their likelihood of adoption and maintenance over time. Practitioners identify cost as the primary factor for which interventions they select to implement, but researchers rarely disseminate cost information or consider its importance when developing new interventions. A new approach is proposed whereby intervention developers assess what individuals and agencies adopting their interventions are willing to pay and then design interventions that are responsive to this price range. The ultimate goal is to develop effective and affordable interventions, called lean interventions, which are widely adopted and have greater public health impact.

Colorectal Cancer Control Program grantees' use of evidence-based interventions.

BACKGROUND: Colorectal cancer (CRC) screening is recommended for adults aged 50-75 years, yet screening rates are low, especially among the uninsured. The CDC initiated the Colorectal Cancer Control Program (CRCCP) in 2009 with the goal of increasing CRC screening rates to 80% by 2014. A total of 29 grantees (states and tribal organizations) receive CRCCP funding to (1) screen uninsured adults and (2) promote CRC screening at the population level. PURPOSE: CRCCP encourages grantees to use one or more of five evidence-based interventions (EBIs) recommended by the Guide to Community Preventive Services. The purpose of the study was to evaluate grantees' EBI use. METHODS: A web-based survey was conducted in 2011 measuring grantees' use of CRC screening EBIs and identifying their implementation partners. Data were analyzed in 2012. RESULTS: Twenty-eight grantees (97%) completed the survey. Most respondents (96%) used small media. Fewer used client reminders (75%); reduction of structural barriers (50%); provider reminders (32%); or provider assessment and feedback (50%). Provider-oriented EBIs were rated as harder to implement than client-oriented EBIs. Grantees partnered with several types of organizations to implement EBIs, many with county- or state-wide reach. CONCLUSIONS: Almost all grantees implement EBIs to promote CRC screening, but the EBIs that may have the greatest impact with CRC screening are implemented by fewer grantees in the first 2 years of the CRCCP.

Preparing to measure health coverage in federal surveys post-reform: lessons from Massachusetts.

In preparation for health reform in 2014, qualitative research was conducted with Massachusetts residents to explore how to adapt surveys to accommodate reporting information about health exchanges. Questions about exchange participation were effective when state-specific exchange program names were offered, but generic terms such as "marketplace" and "exchange" did not resonate with respondents. However, respondents were able to understand new questions about premiums and subsidies and to answer with a high degree of accuracy. These questions, taken in tandem with answers on plan type, were sufficient to distinguish among Medicaid, subsidized exchange coverage, and unsubsidized coverage, even without the benefit of state-specific exchange program names.

An evaluation framework for obesity prevention policy interventions.

As the emphasis on preventing obesity has grown, so have calls for interventions that extend beyond individual behaviors and address changes in environments and policies. Despite the need for policy action, little is known about policy approaches that are most effective at preventing obesity. The Centers for Disease Control and Prevention (CDC) and others are funding the implementation and evaluation of new obesity prevention policies, presenting a distinct opportunity to learn from these practice-based initiatives and build the body of evidence-based approaches. However, contributions from this policy activity are limited by the incomplete and inconsistent evaluation data collected on policy processes and outcomes. We present a framework developed by the CDC-funded Center of Excellence for Training and Research Translation that public health practitioners can use to evaluate policy interventions and identify the practice-based evidence needed to fill the gaps in effective policy approaches to obesity prevention.