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.
Acknowledgements The authors thank the implementation scientists who completed the mapping exercise: Laura Damschroder Joann Kirchner Byron Powell Enola Proctor Jeffrey Smith Thomas Waltz 2
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 outreach intervention aimed at increasing use of a cardiovascular risk calculator • 44/104 participated in Educational Outreach 3
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 4
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 5
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 6
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 7
Rates at which barriers were mentioned by the 44 practices 0 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 8
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. 9
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 .” 10
Mapping Results Barriers Strategies 11
Findings from Mapping Exercise # of barriers for which strategies Implementation strategies were recommended • All 13 barriers by at Develop a formal implementation blueprint with least 1 expert goals and strategies • Facilitation: process of interactive problem solving and support • Provide on-going consultation with experts to support implementation • Across 10 barriers by Assess for readiness/identify barriers and facilitators • at least 1 expert 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 Only 4 strategies were never recommended by an expert for these barriers 12
Findings: Experts recommended many strategies for each barrier No Buy-In Insufficient patient population Time constraints No documented workflow No trust in calculator evidence/ guidelines Staffing Issues Total number of strategies recommended No calculator training Number with high agreement Lack of calculator accessibility Calculator variation No team communication No clinical champion Patient resistance Patient cost issues 0 10 20 30 40 50 60 13
Lessons on Local Adaptation: Tailoring Strategies to Individual Practices Barriers Strategies Organize local team No team implementation meetings communication Provide implementation blueprint Practice #1 Lack of access Small, multi-specialty practice Use data experts to calculator within hospital system in rural town External facilitation No buy-in Training and education No trust in guidelines Practice #11 Prepare and engage Small, single-specialty No calculator champions, opinion leaders, independent practice in a training small city early adopters Time Incentive structures constraints 14
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 15
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. 16
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 17
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 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.
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