Assessment of barriers and facilitators in the implementation of appropriate use criteria for elective percutaneous coronary interventions: a qualitative study

Abstract Background The use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness. Methods All hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC. Results Specific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography. Conclusions The identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI

Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study

Abstract Background Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP. Methods This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA. Discussion The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination