Implementation Science

HomeStrokeVol. 52, No. 12Implementation Science Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBImplementation Science Linda S. Williams, MD and Barbara G. Vickrey, MD, MPH Linda S. WilliamsLinda S. Williams Correspondence to: Linda S. Williams, MD, VA HSR&D, Roudebush VA Medical Center, 1421 West 10th St, Indianapolis, IN, 46202. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9228-9459 VA HSR&D EXTEND QUERI, Indianapolis, IN (L.S.W.). Indiana University School of Medicine, Indianapolis, IN (L.S.W.). Regenstrief Institute, Inc, Indianapolis, IN (L.S.W.). Search for more papers by this author and Barbara G. VickreyBarbara G. Vickrey Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (B.G.V.). Search for more papers by this author Originally published4 Nov 2021https://doi.org/10.1161/STROKEAHA.121.033971Stroke. 2021;52:4054–4056Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 4, 2021: Ahead of Print Implementation Science is an emerging and complex field that primarily focuses on planning, influencing and/or evaluating the adoption of evidence-based practices.1 Evidence of the growing interest in implementation science methods is a 2020 special issue of the Journal of Clinical and Translational Science devoted to Dissemination and Implementation Sciences.2 This issue contains substantive and relevant summaries of current implementation research challenges and the state of the evidence around implementation frameworks and methods, stakeholder engagement strategies, operational and community partnerships, and implementation trial design. In this topical review, we summarize highlights from stroke-related implementation studies published in 2020, organized across the clinical spectrum of stroke care, to illustrate best practices, synthesize lessons learned, and identify implementation tools and methods that may be relevant to the cerebrovascular community.Implementation Science in Acute Stroke CareThe T3 trial (Triage, Treatment, and Transfer) tested a bundled intervention in emergency departments to improve triage, treatment, and transfer of patients with acute stroke. Although the intervention did not improve timeliness of care, an a priori planned implementation analysis was conducted after the trial had concluded. The analysis identified important barriers affecting intervention uptake, including staff readiness to change, fidelity to the protocols, and perceptions of professional boundaries.3 Understanding why this intervention was not successful should guide alternative strategies for future studies focused on improving delivery of acute stroke care in the emergency department setting. A meta-analysis of studies aiming to increase thrombolysis rates in acute stroke analyzed study findings using the behavior change wheel, a conceptual framework of factors that are posited as needing to be addressed to successfully implement complex interventions.4 Five behavior change wheel constructs were found to be commonly employed across these studies: education, persuasion, training, environmental restructuring, and enablement. However, no single strategy or combination of strategies appeared more successful than others for improving thrombolysis rates.Implementation Science in Posthospital Stroke CareThe COMPASS trial (Comprehensive Postacute Stroke Services) reported a process evaluation of the implementation of a transitional care model to improve poststroke outcomes across 19 hospitals in North Carolina. The authors identified organizational, individual, and community factors related to successful implementation.5 Facilitators of change included organizational readiness and the presence of champions; implementation challenges included start-up and staffing in multiple settings and integration of the intervention into existing diverse transitional care programs. The authors concluded the most significant factor identified was the importance of the organization’s commitment and capacity to making a change in how it delivers comprehensive stroke care.Implementation Science in Stroke RehabilitationThe Cochrane collaboration conducted a systematic review of implementation interventions to promote uptake of evidence-based stroke rehabilitation interventions.6 The review suggests it is unclear whether implementation interventions conducted to date actually increase rehabilitation provider or patient adherence to evidence-based practices, and the authors make important recommendations about improvements in design of these implementation studies, to better examine key components of intervention design, fidelity, and impact on provider behavior change. Focusing on intervention fidelity, another study of a community-based exercise program for patients with stroke illustrates use of a formative evaluation—using the Template for Intervention Description and Replication framework—to iteratively monitor and refine intervention implementation.7 A practical study employing a pre-/post design found that a bundle of knowledge translation activities applied within a prespecified framework (the Knowledge-to-Action Framework) was successful in promoting uptake and sustained use of a gait and balance assessment battery over 4 years of clinical implementation.8 This latter study has broad relevance given that many institutions aim to introduce stroke-related care delivery interventions, which are much more likely to be successful if an implementation framework is identified and applied during the planning stages.Implementation Science in Vascular Risk Factor ManagementImplementation of telemonitoring for hypertension was conducted across 75 primary care practices in Scotland, based on prior work to identify key barriers and facilitators, drawing on the capability, opportunity, motivation-behavior change framework, and a prior systematic review of diffusion of innovation approaches. This pragmatic trial found reductions in blood pressure and improved clinical efficiencies in practice. Qualitative evaluation that included staff and patient interviews as well as observation of practices found that integration of data into the routine clinical care systems was particularly critical to implementation success.9 Two implementation studies were reported related to atrial fibrillation management. Lessons from the IMPACT-AFib trial highlighted challenges in embedding pragmatic trials within a health plan, suggesting specific aspects of implementation that should be considered when the intervention occurs at the level of the health plan/insurance company.10 In another study, a pharmacist-led intervention to assist with early detection of atrial fibrillation was found to be feasible, with key drivers of success being the presence of a local champion and strategies enabling effective interprofessional communication.11Implementation Science Methods and ToolsAs evidenced in the work cited above, implementation of health care interventions is often complex and involves multiple stakeholders to facilitate successful program uptake and spread. Use of implementation methods and tools are necessary to deepen real-world learning from studies of complex stroke-related interventions. Several studies cited above demonstrated the benefit of using specific implementation frameworks to guide study design and outcome assessment, to expand our understanding about factors influencing success and failure of implementation of complex stroke care interventions.5,7–9,11 Other studies focused on specific or bundled implementation strategies,3,5,6 with attention to intervention fidelity,7 to identify key drivers of change. There were examples of use of formative evaluation to continually monitor ongoing interventions and incorporate implementation refinements to enhance uptake,7 and summative evaluation to identify generalizable lessons for future implementation of the intervention.11,12 Finally, 2 publications demonstrated the use of innovative implementation science tools, including a summary of methods of economic analysis of implementation interventions (including an example of acute stroke quality improvement assessment),13 and a Research Electronic Data Capture-based database to track stakeholder engagement in the COMPASS trial, an tool that may be of value to other implementation researchers.14Article InformationSources of FundingNone.DisclosuresDr Vickrey receives grant funding for studies of secondary stroke prevention from National Institutes of Health and the American Heart Association.Nonstandard Abbreviations and AcronymsCOMPASSComprehensive Post-Acute Stroke ServicesT3Triage, Treatment, and TransferTIDieRTemplate for Intervention Description and ReplicationFootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 4056.Correspondence to: Linda S. Williams, MD, VA HSR&D, Roudebush VA Medical Center, 1421 West 10th St, Indianapolis, IN, 46202. Email linda.[email protected]govReferences1. National Institutes of Health. PAR 18-007 Dissemination and Implementation Research in Health FOA.2017. Accessed October 25, 2021. https://grants.nih.gov/grants/guide/pa-files/PAR-18-007.html.Google Scholar2. Stevens KR, Tobin JN. Introduction to the JCTS special issue on Dissemination and Implementation Sciences.J Clin Transl Sci. 2020; 4:149–151. doi: 10.1017/cts.2020.488Google Scholar3. McInnes E, Dale S, Craig L, Phillips R, Fasugba O, Schadewaldt V, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, et al. Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study.Implement Sci. 2020; 15:99. doi: 10.1186/s13012-020-01057-0Google Scholar4. Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis.Implement Sci. 2020; 15:98. doi: 10.1186/s13012-020-01054-3Google Scholar5. Lutz BJ, Reimold AE, Coleman SW, Guzik AK, Russell LP, Radman MD, Johnson AM, Duncan PW, Bushnell CD, Rosamond WD, et al. Implementation of a transitional care model for stroke: perspectives from frontline clinicians, administrators, and COMPASS-TC implementation staff.Gerontologist. 2020; 60:1071–1084. doi: 10.1093/geront/gnaa029CrossrefMedlineGoogle Scholar6. Cahill LS, Carey LM, Lannin NA, Turville M, Neilson CL, Lynch EA, McKinstry CE, Han JX, O’Connor D. Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation.Cochrane Database Syst Rev. 2020; 10:CD012575. doi: 10.1002/14651858.CD012575.pub2Google Scholar7. Bird ML, Mortenson WB, Eng JJ. Evaluation and facilitation of intervention fidelity in community exercise programs through an adaptation of the TIDier framework.BMC Health Serv Res. 2020; 20:68. doi: 10.1186/s12913-020-4919-yGoogle Scholar8. Moore JL, Virva R, Henderson C, Lenca L, Butzer JF, Lovell L, Roth E, Graham ID, Hsornby TG. Applying the knowledge-to-action framework to implement gait and balance assessments in inpatient stroke rehabilitation.Arch Phys Med Rehabil. 2020; S0003-9993:31255–31257. doi: 10.1016/j.apmr.2020.10.133Google Scholar9. Hammersley V, Parker R, Paterson M, Hanley J, Pinnock H, Padfield P, Stoddart A, Park HG, Sheikh A, McKinstry B. Telemonitoring at scale for hypertension in primary care: An implementation study.PLoS Med. 2020; 17:e1003124. doi: 10.1371/journal.pmed.1003124CrossrefMedlineGoogle Scholar10. Garcia CJ, Haynes K, Pokorney SD, Lin ND, McMahill-Walraven C, Nair V, Parlett L, Martin D, Al-Khalidi HR, McCall D, et al. Practical challenges in the conduct of pragmatic trials embedded in health plans: Lessons of IMPACT-AFib, an FDA-Catalyst trial.Clin Trials. 2020; 17:360–367. doi: 10.1177/1740774520928426Google Scholar11. da Costa FA, Mala-Ladova K, Lee V, Tous S, Papastergiou J, Griffiths D, Chaumais MC, Hersberger KE, Viola R, Paulino E, et al. Awareness campaigns of atrial fibrillation as an opportunity for early detection by pharmacists: an international cross-sectional study.J Thromb Thrombolysis. 2020; 49:606–617. doi: 10.1007/s11239-019-02000-xGoogle Scholar12. Caughlin S, Mehta S, Corriveau H, Eng JJ, Eskes G, Kairy D, Meltzer J, Sakakibara BM, Teasell R. Implementing telerehabilitation after stroke: lessons learned from Canadian Trials.Telemed J E Health. 2020; 26:710–719. doi: 10.1089/tmj.2019.0097Google Scholar13. Wagner TH, Yoon J, Jacobs JC, So A, Kilbourne AM, Yu W, Goodrich DE. Estimating costs of an implementation intervention.Med Decis Making. 2020; 40:959–967. doi: 10.1177/0272989X20960455Google Scholar14. Gesell SB, Halladay JR, Mettam LH, Sissine ME, Staplefoote-Boynton BL, Duncan PW. Using REDCap to track stakeholder engagement: a time-saving tool for PCORI-funded studies.J Clin Transl Sci. 2020; 4:108–114. doi: 10.1017/cts.2019.444Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 2021Vol 52, Issue 12 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.121.033971PMID: 34732072 Originally publishedNovember 4, 2021 Keywordsmaintenancequality improvementdiffusion of innovationhealthcare quality, access, and evaluationimplementation sciencePDF download Advertisement