Tailoring implementation strategies for CVD risk calculator adoption - - PowerPoint PPT Presentation

Tailoring implementation strategies for CVD risk calculator adoption in primary care practice

Laura-Mae Baldwin, MD, MPH Leah Tuzzio, MPH Erika Holden Jennifer Powell, MPH Allison Cole, MD, MPH Michael Parchman, MD, MPH

This project is supported by grant number R18HS023908 from AHRQ. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

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Acknowledgements

The authors thank the implementation scientists who completed the mapping exercise: Laura Damschroder Joann Kirchner Byron Powell Enola Proctor Jeffrey Smith Thomas Waltz

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Healthy Hearts Northwest (H2N): an AHRQ EvidenceNOW Cooperative

• 4-arm pragmatic clinical trial
• 104/209 small to medium-sized practices

randomized to receive an educational

• utreach intervention aimed at increasing use
• f a cardiovascular risk calculator
• 44/104 participated in Educational Outreach

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Characteristics of 44 Participating Practices

Practice characteristic N practices % Total 44 100 Size (number of providers) Solo (1) 7 16 Small (2-5) 20 45 Medium (6+) 17 39 Location Rural 17 39 Urban 27 61 Type Federally Qualified Health Center 5 11 Health/Hospital System 19 43 IHS/Tribal Health Clinic 3 7 Independent 17 39 Specialty Family Medicine 38 86 Internal Medicine 2 5 Mixed 4 9

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Implemented a Virtual Educational Outreach Program

• Physician educators conducted 30-minute webinar

discussion with clinical care teams

• Intervention included:
• Review of a “detailing aid” with key messages
• Discussion about enablers, barriers, and objections to

implementing CVD risk calculator

• Educators used an intervention toolkit to choose

which content and tools to review based on:

• Background information about the practice
• What they learned during the webinar discussion

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Educator Call Notes

• Educators took field notes during calls on

practices’:

• Experience using a CVD risk calculator
• Barriers and facilitators to implementing

a calculator

• Commitments for next steps in

implementing a calculator

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Identified 13 Barriers to CVD Risk Calculator Implementation

• Calculator-related
• Risk calculator: limited access/no EMR integration
• No or little calculator training
• Different results for different calculators
• Practice-related
• Lack of documented workflow
• No or little team communication (e.g., huddles)
• Time constraints
• Lack of buy-in from providers/staff
• Lack of staff for calculator work
• Clinician-related
• Clinician lack of trust in calculator evidence/guidelines
• No clinical champion
• Patient-related
• Perception of inadequate patient population for using calculator
• Patient resistance/fears
• Cost of medications for patients

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Rates at which barriers were mentioned by the 44 practices

10 20 30 40 50 60 No buy-in Time constraints Patient resistance No documented workflow No trust in guidelines Lack of calculator accessibilty No calculator training Insufficient patient population Staffing issues No clinical champion Patient cost issues Calculator variation No team communication Percent of practices discussing this barrier

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Implementation Expert Mapping Exercise

Invited participation of the authors of

A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project (Waltz et al 2015)

to map the 13 barriers to the 73 evidence-based implementation strategies that they thought could be used to overcome the barriers to implementing the CVD risk calculator in primary care practice. We provided a very short description of the study and the intervention.

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Comments on the Mapping Exercise

Experts found the exercise difficult:

• “Completing this myself made me appreciate

how difficult it is to do this without fully knowing the intervention and the context well…often times I found myself wondering about the root causes of the barriers…I am increasingly convinced that we need to get even more detailed with both our strategies and our articulation of the barriers in a way that will allow us to more tightly link barriers and determinants.”

• “This is never an easy task. Doing this kind of

exercise (again) reinforces just why we find such diversity in selection of strategies.”

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Mapping Results

Barriers Strategies

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Findings from Mapping Exercise

Only 4 strategies were never recommended by an expert for these barriers # of barriers for which strategies were recommended

Implementation strategies

All 13 barriers by at least 1 expert

• Develop a formal implementation blueprint with

goals and strategies

• Facilitation: process of interactive problem solving

and support

• Provide on-going consultation with experts to

support implementation Across 10 barriers by at least 1 expert

• Assess for readiness/identify barriers and facilitators
• Identify and prepare champions
• Tailor strategies
• Promote adaptability
• Inform local opinion leaders
• Train and educate stakeholders
• Conduct local consensus discussions
• Distribute educational materials
• Conduct educational meetings

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Findings: Experts recommended many strategies for each barrier

10 20 30 40 50 60 Patient cost issues Patient resistance No clinical champion No team communication Calculator variation Lack of calculator accessibility No calculator training Staffing Issues No trust in calculator evidence/ guidelines No documented workflow Time constraints Insufficient patient population No Buy-In Total number of strategies recommended Number with high agreement

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Lessons on Local Adaptation: Tailoring Strategies to Individual Practices

Practice #1

Small, multi-specialty practice within hospital system in rural town

Provide implementation blueprint Use data experts External facilitation

Practice #11

Small, single-specialty independent practice in a small city

No trust in guidelines No calculator training Prepare and engage champions, opinion leaders, early adopters No team communication Lack of access to calculator No buy-in Incentive structures Time constraints Strategies Barriers Training and education Organize local team implementation meetings

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Limitations

• Barriers were specific to the

implementation of CVD risk calculator

• Implementation experts may have

responded differently if given:

• more information about intervention and

barriers

• limits on the number of strategies they

could choose

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Conclusions

• Some implementation strategies may be

fundamental to practice change, regardless of individual practice barriers

• Tailoring of strategies may help overcome individual

clinic barriers to implementation

• More work is needed: How to best match strategies

to barriers

• Full understanding of the intervention, the context into

which it will be implemented, and the barriers to implementation

• Strategies may need to be added to the current set of 73

ERIC-generated strategies to address some barriers.

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Next Steps

• Test whether tailoring implementation

strategies to a practice’s context and barriers to implementing an intervention results in:

• better uptake of an intervention
• improved clinical outcomes

This project is supported by grant number R18HS023908 from the Agency for Healthcare Research and Quality (AHRQ). Healthy Hearts Northwest is a cooperative of AHRQ’s EvidenceNOW initiative to advance heart health in primary care.

For more information:

About the Educational Outreach Program or this study, contact Laura-Mae Baldwin: lmb@uw.edu About H2N or this study, visit www.healthyheartsnw.org and contact Michael Parchman: parchman.m@ghc.org or Leah Tuzzio: tuzzio.l@ghc.org