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1.
FASEB Bioadv ; 3(8): 626-638, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34377958

RESUMO

The Veterans Health Administration (VHA), under the U.S. Department of Veterans Affairs (VA), is one of the largest single providers of health care in the U.S. VA supports an embedded research program that addresses VA clinical priorities in close partnership with operations leaders, which is a hallmark of a Learning Health System (LHS). Using the LHS framework, we describe current VA research initiatives in mental health and substance use disorders that rigorously evaluate national programs and policies designed to reduce the risk of suicide and opioid use disorder (data to knowledge); test implementation strategies to improve the spread of effective programs for Veterans at risk of suicide or opioid use disorder (knowledge to performance); and identify novel research directions in suicide prevention and opioid/pain treatments emanating from implementation and quality improvement research (performance to data). Lessons learned are encapsulated into best practices for building and sustaining an LHS within health systems, including the need for early engagement with clinical leaders; pragmatic research questions that focus on continuous improvement; multi-level, ongoing input from regional and local stakeholders, and business case analyses to inform ongoing investment in sustainable infrastructure to maintain the research-health system partnership. Essential ingredients for supporting VA as an LHS include data and information sharing capacity, protected time for researchers and leaders, and governance structures to enhance health system ownership of research findings. For researchers, incentives to work with health systems operations (e.g., retainer funding) are vital for LHS research to be recognized and valued by academic promotion committees.

2.
J Consult Clin Psychol ; 89(6): 537-550, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34264701

RESUMO

OBJECTIVE: To determine if the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) improves functional impairment, psychiatric symptoms, and sleep and circadian functioning. METHOD: Adults diagnosed with serious mental illness (SMI) and sleep and circadian dysfunction (N = 121) were randomly allocated to TranS-C plus usual care (TranS-C + UC; n = 61; 8 individual weekly sessions) or 6 months of Usual Care followed by Delayed Treatment with TranS-C (UC-DT; n = 60). Schizophrenia (45%) and anxiety disorders (47%) were common. Blind assessments were conducted pre-treatment, post-treatment, and 6 months later (6FU). The latter two were the post-randomization points of interest. The location was Alameda County Behavioral Health Care Services (ACBHCS), a Community Mental Health Center (CMHC) in California. RESULTS: For the primary outcomes, relative to UC-DT, TranS-C + UC was associated with reduction in functional impairment (b = -3.18, p = 0.025, d = -0.58), general psychiatric symptoms (b = -5.88, p = 0.001, d = -0.64), sleep disturbance (b = -5.55, p < .0001, d = -0.96), and sleep-related impairment (b = -9.14, p < .0001, d = -0.81) from pre-treatment to post-treatment. These effects were maintained to 6-month follow-up (6FU; d = -0.42 to -0.82), except functional impairment (d = -0.37). For the secondary outcomes, relative to UC-DT, TranS-C + UC was associated with improvement in sleep efficiency and on the Sleep Health Composite score from pre-treatment to 6FU. TranS-C + UC was also associated with reduced total wake time and wake time variability from pre-treatment to post-treatment, as well as reduced hallucinations and delusions, bedtime variability, and actigraphy measured waking activity count variability from pre-treatment to 6FU. CONCLUSIONS: A novel transdiagnostic treatment, delivered within a CMHC setting, improves selected measures of functioning, symptoms of comorbid disorders, and sleep and circadian outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).


Assuntos
Centros Comunitários de Saúde Mental , Transtornos Mentais/terapia , Psicoterapia/métodos , Transtornos do Sono do Ritmo Circadiano/terapia , Transtornos do Sono-Vigília/terapia , Adulto , Ansiedade/terapia , Transtornos de Ansiedade/terapia , California , Feminino , Humanos , Masculino , Transtornos Mentais/complicações , Pessoa de Meia-Idade , Esquizofrenia/terapia , Sono , Transtornos do Sono do Ritmo Circadiano/complicações , Transtornos do Sono-Vigília/complicações , Resultado do Tratamento
3.
Healthc (Amst) ; 8 Suppl 1: 100455, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34175093

RESUMO

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.

4.
Front Public Health ; 9: 655999, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34109147

RESUMO

Background: Despite increasing calls for further spread of evidence-based collaborative care interventions (EBIs) in community-based settings, practitioner-driven efforts are often stymied by a lack of experience in addressing barriers to community-based implementation, especially for those not familiar with implementation science. The Michigan Mental Health Integration Partnership (MIP) is a statewide initiative that funds projects that support implementation and uptake of EBIs in community-based settings. MIP also provides an in situ implementation laboratory for understanding barriers to the uptake of EBIs across a variety of settings. We report findings from a statewide qualitative study of practitioners involved in MIP projects to garner their perspectives of best practices in the implementation of EBIs. Methods: Twenty-eight semi-structured interviews of practitioners and researchers from six MIP Projects were conducted with individuals implementing various MIP EBI projects across Michigan, including stakeholders from project teams, implementation sites, and the State of Michigan, to identify common barriers, challenges, and implementation strategies deployed by the project teams, with the purpose of informing a set of implementation steps and milestones. Results: Stakeholders identified a number of barriers to and strategies for success, including the need for tailoring program deployment and implementation to specific site needs, development of web-based tools for facilitating program implementation, and the importance of upper-level administration buy-in. Findings informed our resultant community-based Implementation Roadmap, which identifies critical steps across three implementation phases-pre-implementation, implementation, and sustainability-for implementation practitioners to use in their EBI implementation efforts. Conclusion: Implementation practitioners interested in community-based EBI implementation often lack access to operationalized implementation "steps" or "best practices" that can facilitate successful uptake and evaluation. Our community-informed MIP Implementation Roadmap, offering generalized steps for reaching successful implementation, uses experiences from a diverse set of MIP teams to guide practitioners through the practices necessary for scaling up EBIs in community-based settings over pre-implementation, implementation and sustainability phases.


Assuntos
Ciência da Implementação , Saúde Mental , Serviços de Saúde , Humanos , Michigan , Pesquisa Qualitativa
5.
Acad Pediatr ; 21(7): 1195-1202, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34098172

RESUMO

OBJECTIVE: The aim of the current study was to evaluate primary care pediatrician (PCP) adoption of an electronic health record (EHR) documentation tool and their delivery of a behavioral activation (BA) intervention within their routine practice with adolescents who screened positive for depression. METHODS: We used the RE-AIM framework to describe PCP adoption and implementation of EHR documentation tools and brief evidence-based protocols. Utilization was assessed using a customized toolbar (ie, actions toolbar) via retrospective chart review. A pre-post design was used to measure changes in PCP-reported knowledge, comfort, and feasibility managing depression before and after they were trained. A mixed-effects logistic regression model was used to analyze associations of resource utilization with depression severity. RESULTS: PCPs used the actions toolbar to document responses to elevated Patient Health Questionnaire (PHQ-9) scores for 29.80% of encounters. The PCPs utilized the BA protocol for 10.5% of encounters with elevated PHQ-9 scores. Higher depression severity categories were associated with significantly higher odds of utilization relative to mild severity. The training was rated highly acceptable and PCPs reported significant post-training increases in comfort and feasibility. CONCLUSION: This is the first study of its kind to implement and evaluate PCP utilization of an EHR documentation tool aimed to improve delivery of an evidence-based intervention for adolescent depression. Teaching PCPs to implement brief interventions has potential to increase access to evidence-based care; however, large-scale practice change requires an effective implementation strategy that does not increase provider burden and is fully integrated into physician documentation and workflow.


Assuntos
Depressão , Registros Eletrônicos de Saúde , Adolescente , Depressão/diagnóstico , Depressão/terapia , Documentação , Humanos , Atenção Primária à Saúde , Estudos Retrospectivos
6.
JAMA Netw Open ; 4(5): e216836, 2021 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-33978723

RESUMO

Importance: Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice. Objective: To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. Design, Setting, and Participants: This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. Main Outcomes and Measures: The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. Results: Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. Conclusions and Relevance: This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

7.
Jt Comm J Qual Patient Saf ; 47(4): 217-227, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33549485

RESUMO

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.


Assuntos
United States Department of Veterans Affairs , Saúde dos Veteranos , Humanos , Motivação , Estados Unidos
8.
J Gen Intern Med ; 36(2): 500-505, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32869192

RESUMO

Many of the most pressing health issues in the USA and worldwide require complex, multi-faceted solutions. Delivery of such solutions is often complicated by the need to reach and engage vulnerable populations facing multiple barriers to care. While the fields of quality improvement and implementation science have made valuable gains in the development and spread of individual strategies to improve evidence-based practice delivery, models for coordinated deployment of numerous strategies to simultaneously implement multiple evidence-based interventions in vulnerable populations are lacking. In this Perspective, we describe a model for this type of comprehensive research-practice translation effort: the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, which is focused on reducing premature mortality in the population with serious mental illness. We describe the Center's conceptual framework, which is built upon an integrated set of quality improvement and implementation science frameworks, provide an overview of the Center's organizational structure and core research-practice translation activities, and discuss our vision for how the Center may evolve over time. Lessons learned from this Center's efforts could inform models to address other critical health issues in vulnerable populations that require multi-component solutions at the policy, system, provider, and patient levels.


Assuntos
Longevidade , Transtornos Mentais , Humanos , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia
9.
J Gen Intern Med ; 36(2): 506-510, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32918200

RESUMO

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.


Assuntos
Pessoal de Saúde , Resolução de Problemas , Atenção à Saúde , Humanos , Ciência da Implementação
10.
J Gen Intern Med ; 36(2): 396-403, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32875498

RESUMO

BACKGROUND: Measuring the health, economic, and cultural gains generated by scientific investments is crucial to reducing waste and improving quality of care. To date, there is no comprehensive framework for assessing the multi-faceted contributions of implementation and quality improvement sciences towards quality, cost, and patient and provider experiences in health systems. OBJECTIVE: We describe the Quality Enhancement Research Initiative (QUERI) Impact Framework and its application to QUERI investments. METHODS: The QUERI Impact Framework adapts and expands on metrics from the National Academy of Medicine, incorporating lessons learned from QUERI initiatives. The cross-cutting impact metrics reflect QUERI's strategic methodology across five domains of impact (Alignment, Commitment, Tailoring, Informing the field, Observing healthcare changes and generating New questions/projects or ACTION). Key impact metrics, including the number of implementation facilities, number of staff trained, and number of patients served, were derived directly from health system performance plan goals. QUERI applied the Framework by conducting iterative rapid assessments of impacts for QUERI Program centers, which are implementation laboratories that support 3-7 initiatives aligned with a cross-disciplinary goal addressing a national priority. KEY RESULTS: From October 2015 to September 2019, QUERI Programs supported implementation of 49 evidence-based practices and promising innovations across 465 facilities, including 15 facilities that are experiencing quality gaps. As part of these implementation efforts, the programs worked with 71 operations partners to develop 71 tools/toolkits/manuals and support training of 5147 VA staff, serving 250,159 Veterans. CONCLUSIONS: The QUERI Impact Framework aligns multiple stakeholders at different levels of a health system around common metrics, which cross implementation science and quality improvement boundaries. The Framework supports a comprehensive assessment of the short-term and distal impacts of implementation efforts in a health system, allowing both research and operations leadership to understand the value of implementation and quality improvement investments to inform program and policy decisions.


Assuntos
Ciência da Implementação , United States Department of Veterans Affairs , Benchmarking , Atenção à Saúde , Humanos , Melhoria de Qualidade , Estados Unidos
11.
Implement Sci ; 15(1): 109, 2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33317593

RESUMO

BACKGROUND: Theory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP. METHODS: We used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA). RESULTS: Our results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY. CONCLUSIONS: Our results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.

12.
Med Decis Making ; 40(8): 959-967, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33078681

RESUMO

Health care systems frequently have to decide whether to implement interventions designed to reduce gaps in the quality of care. A lack of information on the cost of these interventions is often cited as a barrier to implementation. In this article, we describe methods for estimating the cost of implementing a complex intervention. We review methods related to the direct measurement of labor, supplies and space, information technology, and research costs. We also discuss several issues that affect cost estimates in implementation studies, including factor prices, fidelity, efficiency and scale of production, distribution, and sunk costs. We examine case studies for stroke and depression, where evidence-based treatments exist and yet gaps in the quality of care remain. Understanding the costs for implementing strategies to reduce these gaps and measuring them consistently will better inform decision makers about an intervention's likely effect on their budget and the expected costs to implement new interventions.

13.
Health Serv Res ; 55(6): 954-965, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33125166

RESUMO

OBJECTIVE: To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support. STUDY SETTING: Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization. STUDY DESIGN: Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses. DATA COLLECTION: Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. PRINCIPAL FINDINGS: N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (ΔEF/IF-EF  = 4.4 patients, 95% CI = 1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF-EF  = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF-EF  = -0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators. CONCLUSIONS: Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.


Assuntos
Doença Crônica/terapia , Serviços de Saúde Comunitária/organização & administração , Modelos Organizacionais , Planejamento de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Serviços de Saúde Comunitária/normas , Pesquisa Comparativa da Efetividade , Comportamento Cooperativo , Prática Clínica Baseada em Evidências , Sistemas de Informação em Saúde/organização & administração , Humanos , Administração dos Cuidados ao Paciente/organização & administração , Atenção Primária à Saúde/normas , Autogestão , Estados Unidos
15.
JMIR Ment Health ; 7(9): e19476, 2020 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-32960185

RESUMO

BACKGROUND: There is considerable scientific interest in finding new and innovative ways to capture rapid fluctuations in functioning within individuals with bipolar disorder (BD), a severe, recurrent mental disorder associated with frequent shifts in symptoms and functioning. The use of smartphones can provide valid and real-world tools for use in measurement-based care and could be used to inform more personalized treatment options for this group, which can improve standard of care. OBJECTIVE: We examined the feasibility and usability of a smartphone to capture daily fluctuations in mood within BD and to relate daily self-rated mood to smartphone use behaviors indicative of psychomotor activity or symptoms of the illness. METHODS: Participants were 26 individuals with BD and 12 healthy control individuals who were recruited from the Prechter Longitudinal Study of BD. All were given a smartphone with a custom-built app and prompted twice a day to complete questions of mood for 28 days. The app automatically and unobtrusively collected phone usage data. A poststudy satisfaction survey was also completed. RESULTS: Our sample showed a very high adherence rate to the daily momentary assessments (91% of the 58 prompts completed). Multivariate mixed effect models showed that an increase in rapid thoughts over time was associated with a decrease in outgoing text messages (ß=-.02; P=.04), and an increase in impulsivity self-ratings was related to a decrease in total call duration (ß=-.29; P=.02). Participants generally reported positive experiences using the smartphone and completing daily prompts. CONCLUSIONS: Use of mobile technology shows promise as a way to collect important clinical information that can be used to inform treatment decision making and monitor outcomes in a manner that is not overly burdensome to the patient or providers, highlighting its potential use in measurement-based care.

16.
J Clin Transl Sci ; 4(3): 195-200, 2020 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-32695488

RESUMO

Translation of research to practice is challenging. In addition to the scientific challenges, there are additional hurdles in navigating the rapidly changing US health care system. There is a need for innovative health interventions that can be adopted in "real-world" settings. Barriers to translation involve misaligned timing of research funding and health system decision-making, lack of research questions aligned with health system and community priorities, and limited incentives in academia for health system and community-based research. We describe new programs from the US Department of Veterans Affairs Health Services Research and Development (HSR&D) and the National Center for Advancing Translational Sciences (NCATS) Clinical and Translational Science Award (CTSA) Programs that are building capacity for Learning Health System research. These programs help to incentivize adopting and adapting Learning Health System principles to ensure that, primarily in implementation science within academic/veterans affairs health systems, there is alignment of the research with the health system and community needs. Both HSR&D and NCATS CTSA Program encourage researchers to develop problem-focused research innovations in partnership with health systems and communities to ultimately facilitate design treatments that are feasible in "real-world" practice.

17.
J Sch Health ; 90(6): 447-456, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32227345

RESUMO

BACKGROUND: The Michigan Model for Health™ (MMH) is the official health curriculum for the State of Michigan and prevailing policy and practice has encouraged its adoption. Delivering evidence-based programs such as MMH with fidelity is essential to program effectiveness. Yet, most schools do meet state-designated fidelity requirements for implementation (delivering 80% or more of the curriculum). METHODS: We collected online survey (N = 20) and in-person interview (N = 5) data investigating fidelity and factors related to implementation of the MMH curriculum from high school health teachers across high schools in one socioeconomically challenged Michigan county and key stakeholders. RESULTS: We found that 68% of teachers did not meet state-identified standards of fidelity for curriculum delivery. Our results indicate that factors related to the context and implementation processes (eg, trainings) may be associated with fidelity. Teachers reported barriers to program delivery, including challenges with adapting the curriculum to suit their context, competing priorities, and meeting students' needs on key issues such as substance use and mental health issues. CONCLUSIONS: Multiple factors influence the fidelity of health curriculum delivery in schools serving low-income students. Investigating these factors guided by implementation science frameworks can inform use of implementation strategies to support and enhance curriculum delivery.

18.
Prev Sci ; 21(6): 820-829, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32307625

RESUMO

Intervention effects observed in efficacy trials are rarely seen when programs are broadly disseminated, underscoring the need to better understand factors influencing fidelity. The Michigan Model for Health™ (MMH) is an evidence-based health curriculum disseminated in schools throughout Michigan that is widely adopted but delivered with limited fidelity. Understanding implementation determinants and how they influence fidelity is essential to achieving desired implementation and behavioral outcomes. The study surveyed health teachers throughout Michigan (n = 171) on MMH implementation, guided by the Consolidated Framework for Implementation Research. We investigated relationships between context, intervention and provider factors and dose delivered (i.e., the proportion of curriculum delivered by teachers), a fidelity dimension. We also examined whether intervention factors were moderated by provider factors to influence fidelity. Our results indicated that program packaging ratings were associated with dose delivered (fidelity). We also found that this relationship was moderated by teacher experience. The strength of this relationship diminished with increasing levels of experience, with no relationship among the most experienced teachers. Intervention adaptability was also associated with dose delivered. We found no association between health education policies (context), provider beliefs, and dose delivered. Intervention factors are important determinants of fidelity. Our results suggest that providers with more experience may need materials tailored to their knowledge and skill level to support materials' continued usefulness and fidelity long-term. Our results also suggest that promoting adaptability may help enhance fidelity. Implementation strategies that focus on systematically adapting evidence-based health programs may be well suited to enhancing the fidelity of the MMH curriculum across levels of teacher experience.

19.
Health Justice ; 8(1): 2, 2020 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-31938876

RESUMO

BACKGROUND: School safety is fundamental to fostering positive outcomes for children. Violence remains a critical public health issue with 8.1% of elementary and 21.8% of middle school students reporting daily or weekly bullying in 2015-16. Similarly, over half of lifetime mental health concerns become evident before age 14. Thus, elementary school is a key time for comprehensive school safety interventions. Yet, interventions are rarely delivered with fidelity in community settings. Evidence-based interventions must be complemented by implementation strategies to achieve desired public health outcomes. METHODS: We develop and test an intervention focused on promoting a positive school climate guided by a school-based 3-person leadership team (3-PLT) using a hybrid Type II design. The 3-PLT includes a School Resource Officer, (SRO), administrator and mental health services professional as a newly appointed climate specialist (CS). The interventions to be delivered include 1) Restorative justice, 2) Mental Health First Aid and 3) Crime Prevention Through Environmental Design. The CS will lead the team and coordinate implementation through a process of interactive problem solving and supports, consistent with the implementation facilitation strategy. We will conduct a cluster randomized controlled trial with staged entry over two school years in Genesee County, Michigan (n = 20 elementary schools, with 10 participating per school year). We will use a combination of data sources including data collected by schools (e.g., discipline data), a student survey, and a teacher survey. We will also conduct a process evaluation and assess implementation and sustainability through focus groups with key stakeholders, teachers, and students. Finally, we will conduct a cost-benefit analysis. DISCUSSION: Results from both the behavioral outcome and implementation strategy evaluations are expected to have significant implications for school safety and student well-being. This study adopts a unique approach by integrating three evidence-based programs and incorporating implementation facilitation led by the CS as part of the 3-PLT to support intervention delivery and enhance public health impact among schools in disadvantaged communities with students at risk of poor health outcomes. This study aims to create a comprehensive, well-integrated model intervention that is sustainable and can be translated to similar high-risk settings. TRIAL REGISTRATION: Trial was retrospectively registered, registration ISRCTN1226421, May 16, 2019.

20.
Psychiatry Res ; 283: 112433, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31202612

RESUMO

Implementation researchers have made notable progress in developing and testing implementation strategies (i.e., highly-specified methods used to help providers improve uptake of mental health evidence-based practices: EBPs). Yet, implementation strategies are not widely applied in healthcare organizations to improve delivery of EBPs. Economic considerations are a key factor influencing the use of implementation strategies to deliver and sustain mental health evidence-based practices, in part because many health care leaders are reluctant to invest in ongoing implementation strategy support without knowing the return-on-investment. Comparative economic evaluation of implementation strategies provides critical information for payers, policymakers, and providers to make informed decisions if specific strategies are an efficient use of scarce organizational resources. Currently, few implementation studies include implementation cost data and even fewer conduct comparative economic analyses of implementation strategies. This summary will introduce clinicians, researchers and other health professionals to the economic evaluation in implementation science. We provide an overview of different economic evaluation methods, discuss differences between economic evaluation in health services and implementation science. We also highlight approaches and frameworks to guide economic evaluation of implementation, provide an example for a cognitive-behavioral therapy program and discuss recommendations.


Assuntos
Análise Custo-Benefício/métodos , Atenção à Saúde/economia , Atenção à Saúde/métodos , Ciência da Implementação , Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/métodos , Prática Clínica Baseada em Evidências/economia , Prática Clínica Baseada em Evidências/métodos , Humanos , Transtornos Mentais/economia , Transtornos Mentais/terapia , Saúde Mental
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