Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Abstract Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.http://deepblue.lib.umich.edu/bitstream/2027.42/78272/1/1748-5908-4-50.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/2/1748-5908-4-50-S1.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/3/1748-5908-4-50-S3.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/4/1748-5908-4-50-S4.PDFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/5/1748-5908-4-50.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78272/6/1748-5908-4-50-S2.PDFPeer Reviewe

Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations

BACKGROUND: Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery. METHODS: Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts. RESULTS: Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows. CONCLUSIONS: eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users

Co-morbidade fadiga e depressão em pacientes com câncer colo-retal Enfermedad concomitante: fatiga y depresión en pacientes con cáncer colon-rectal Comorbidities between fatigue and depression in patients with colorectal cancer

O estudo teve como objetivos caracterizar e identificar a comorbidade entre fadiga e depressão em pacientes com câncer colorretal. A amostra não-probabilística foi de 154 pacientes ambulatoriais (53% homens; idade média 49,6&plusmn;11,7 anos; escolaridade média 8,9&plusmn;5,4 anos). A fadiga foi avaliada pela Escala de Fadiga de Piper Revisada e o humor pelo Inventário de Depressão de Beck. A Fadiga foi relatada por 76 (49,4%) pacientes e foi intensa (escore total > 6) para 19,7% deles. Escores que sugerem depressão (IDB>20) foram encontrados em 11 (7,1%) pacientes. Fadiga e depressão estavam correlacionadas (r=0,395; p 0,001). A co-morbidade fadiga moderada/intensa e disforia/depressão ocorreu em 12,3%. A Fadiga estava presente na totalidade dos doentes deprimidos (100%), e a depressão ocorreu em 18% dos doentes fatigados. Fadiga e depressão são fenômenos relacionados, a sua comorbidade pode ser muito deletéria ao doente; a depressão foi mais importante para a ocorrência de fadiga do que a fadiga para a depressão.<br>El estudio tuvo como objetivos caracterizar e identificar la relación entre la fatiga y la depresión en pacientes con cáncer colon-rectal. La muestra no probabilística fue de 154 pacientes de ambulatorio (53% hombres; edad promedio 49,6&plusmn;11,7 años; escolaridad promedio 8,9&plusmn;5,4 anos). La fatiga fue evaluada por la Escala de Fatiga de Piper Revisada y el humor por el Inventario de Depresión de Beck. La Fatiga fue relatada por 76 (49,4%) pacientes y fue intensa (puntaje total > 6) para 19,7% de ellos. Puntajes que sugieren depresión (IDB>20) fueron encontrados en 11 (7,1%) pacientes. La fatiga y la depresión estaban correlacionados (r= 0,395; p 0,001). La enfermedad concomitante fatiga moderada/intensa y disforia/depresión ocurrió en 12,3%. La Fatiga estaba presente en la totalidad de los enfermos deprimidos (100%), y la depresión ocurrió en 18% de los enfermos fatigados. Fatiga y depresión son fenómenos relacionados (concomitantes), y su acción puede ser muy deletérea para el enfermo; la depresión fue más importante para la ocurrencia de fatiga que la fatiga para la depresión.<br>The objective of this study was to identify and characterize the comorbidities of fatigue and depression in colorectal cancer patients. A non-probabilistic sample of 154 outpatients (53% men; mean age 49.6&plusmn;11.7 years; mean education 8.9&plusmn;5.4 years). Fatigue was evaluated using the Revised Piper Fatigue Scale (min:0; max:10) and depression was evaluated using the Beck Depression Inventory (BDI) (min:0; max: 63). Fatigue was identified by 76 (49.4%) patients, and was intense (total score > 6) for 19.7% . Scores compatible with depression (BDI> 20) were found in 11 (7.1%) patients. Fatigue and depression were correlated (r= 0.395, p<0.001). Comorbidities of moderate/severe fatigue and dysphoria/depression occurred in 12.3%. Fatigue was present in all patients with depression (100%) and depression occurred in 18% of patients with fatigue. Fatigue and depression are related phenomena. Comorbidities can be deleterious to the patient. Depression had a stronger effect on the occurrence of fatigue than the effect of fatigue on depression