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Background: Female sex workers (FSWs) face a confluence of multilevel barriers to HIV care. In South Africa, 63% of FSWs are living with HIV and, <40% are virally suppressed. The objective of this analysis was to identify implementation determinants of 2 HIV treatment support strategies. Methods: The Siyaphambili trial tested a decentralized treatment provision and an individualized case management strategy aimed to support FSWs living with unsuppressed HIV viral loads. We identified a nested sample of trial participants using maximum variation sampling (n = 36) as well as a purposively selected sample of implementors (n = 12). We used semistructured interview guides, developed using the Consolidated Framework for Implementation Research (CFIR) and deductively coded the transcripts using CFIR, systematically assessing the strength and valence of implementation. We compared construct ratings to determine whether any constructs distinguished implementation across strategies. Results: Across 3 CFIR domains (innovation characteristics, inner setting, and outer setting), 12 constructs emerged as facilitating, hindering, or having mixed effects on strategy implementation. The relative advantage, design, adaptability, and complexity constructs of the innovation characteristics and the work infrastructure construct of the inner setting were strongly influential (± 2 or +2). While the majority of construct valence and strength rating (9–12) were not distinguishing across strategies, we observed 3 weakly distinguishing CFIR constructs (relative advantage, complexity, and available resources). Conclusions: Given the potential benefits of differentiated service delivery strategies, identifying the relative importance of implementation determinants facilitates transparency and evaluation, supporting future strategy design and implementation. Optimizing implementation will support addressing inequities in HIV care and treatment services. [ABSTRACT FROM AUTHOR]

Introduction: Scientific evidence indicates that the community-based rehabilitation (CBR) model is recommended for recovery from mental disorders. However, this approach encounters barriers and often lacks implementation strategies. Aim: The aim of this study was to create a strategy for the implementation of CBR for mental health in Colombia through the identification of barriers and facilitators, together with the expected outcomes, from the perspective of mental health decision-makers in Colombia. Methods: This study adopts a qualitative descriptive approach, using focus group data collection methods and thematic analysis to code and analyze the data. Results: A total of 208 individuals participated in the study, including mental health decision-makers and health care professionals. Intersectoral collaboration, contextualization, financial resources, and community commitment and autonomy were identified as barriers and facilitators. The element that was considered a priority for successful implementation was the contextualization of strategies. Conclusions: CBR needs to be strengthened through implementation science if these strategies are to be successfully developed and implemented in various contexts [ABSTRACT FROM AUTHOR]

The emerging field of implementation science (IS) facilitates the sustainment of evidence-based practice in clinical care. This article, the second in a series on applying IS, describes how a nurse-led IS team at a multisite health system implemented the Brøset Violence Checklist--a validated, evidence-based tool to predict a patient's potential to become violent--in the system's adult EDs, with the aim of decreasing the rate of violence against staff. The authors discuss how they leveraged IS concepts, methods, and tools to achieve this goal. [ABSTRACT FROM AUTHOR]

Obesity is a recognized public health epidemic with a prevalence that continues to increase dramatically in nearly all populations, impeding progress in reducing incidence rates of cardiovascular disease. Over the past decade, obesity science has evolved to improve knowledge of its multifactorial causes, identifying important biological causes and sociological determinants of obesity. Treatments for obesity have also continued to develop, with more evidence-based programs for lifestyle modification, new pharmacotherapies, and robust data to support bariatric surgery. Despite these advancements, there continues to be a substantial gap between the scientific evidence and the implementation of research into clinical practice for effective obesity management. Addressing barriers to obesity science implementation requires adopting feasible methodologies and targeting multiple levels (eg, clinician, community, system, policy) to facilitate the delivery of obesitytargeted therapies and maximize the effectiveness of guideline-driven care to at-need patient populations. This scientific statement (1) describes strategies shown to be effective or promising for enhancing translation and clinical application of obesity-based research; (2) identifies key gaps in the implementation of obesity science into clinical practice; and (3) provides guidance and resources for health care professionals, health care systems, and other stakeholders to promote broader implementation and uptake of obesity science for improved population-level obesity management. In addition, advances in implementation science that hold promise to bridge the know-do gap in obesity prevention and treatment are discussed. Last, this scientific statement highlights implications for health research policy and future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care. [ABSTRACT FROM AUTHOR]

Background: Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population. Setting: Ward 86, a clinic serving publicly insured PWH in San Francisco. Methods: We describe multilevel determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on preimplementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process. Results: Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Providerlevel determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers because of rapid and unconstrained inclusion of LA-CAB/ RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication. Conclusions: Multilevel strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed. [ABSTRACT FROM AUTHOR]

Background: Ukraine has implemented ambitious HIV-prevention programs since 1999 and began offering preexposure prophylaxis (PrEP) in 2017. Little is known about PrEP uptake and persistence in this setting. Setting: We analyzed data from 40 facilities providing PrEP in 11 oblasts (regions) of Ukraine between October 2020 and February 2022. Methods: We estimated the time between PrEP visits and conducted Kaplan--Meier analyses to estimate retention on PrEP stratified by sex, age, and key populations (KPs): men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), discordant couples, and others vulnerable to HIV acquisition (DC/other). We used Cox regression to estimate the risk of PrEP discontinuation by KP group and sex, adjusting for age. Results: Overall, 2033 clients initiated PrEP across regions; the majority (51%) were DC/other, 22% were MSM, 22% were PWID, and 5% were SW. The overall 3-month persistence was 52.3% (95% confidence interval [CI]: 49.9% to 54.8%) and was lowest among MSM (46.7%; 95% CI: 41.9% to 52.2%) and SW (25.9%; 95% CI: 18.2% to 36.9%) (P, 0.05 for differences by KP group). After adjusting for age, PrEP discontinuation was not statistically significantly different across groups, although female PWID tended to have the lowest discontinuation risk (adjusted hazard ratio [aHR] 0.59; 95% CI: 0.31 to 1.11) while male SW tended to have the highest risk (aHR 1.87, 95% CI: 0.57 to 6.11) compared with females in the DC/other group. Conclusion: Three-month PrEP persistence was low across KP groups, especially in SW. Further research examining the barriers and enablers of persistence by KPs is needed. [ABSTRACT FROM AUTHOR]

Background: Intervention packages may result in a greater public health impact than single interventions. Understanding the separate impact of each component on the overall package effectiveness can improve intervention delivery. Methods: We adapted an approach to evaluate the effects of a time-varying intervention package in a network-randomized study. In some network-randomized studies, only a subset of participants in exposed networks receive the intervention themselves. The spillover effect contrasts average potential outcomes if a person was not exposed to themselves under intervention in the network versus no intervention in a control network. We estimated the effects of components of the intervention package in HIV Prevention Trials Network 037, a Phase III network-randomized HIV prevention trial among people who inject drugs and their risk networks using marginal structural models to adjust for time-varying confounding. The index participant in an intervention network received a peer education intervention initially at baseline, then boosters at 6 and 12 months. All participants were followed to ascertain HIV risk behaviors. Results: There were 560 participants with at least one follow-up visit, 48% of whom were randomized to the intervention, and 1,598 participant visits were observed. The spillover effect of the boosters in the presence of initial peer education training was a 39% rate reduction (rate ratio = 0.61; 95% confidence interval = 0.43, 0.87). Conclusions: These methods will be useful for evaluating intervention packages in studies with network features. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Accurate glomerular filtration rate (GFR) assessment is essential in critically ill patients. GFR is often estimated using creatinine-based equations, which require surrogates for muscle mass such as age and sex. Race has also been included in GFR equations, based on the assumption that Black individuals have genetically determined higher muscle mass. However, race-based GFR estimation has been questioned with the recognition that race is a poor surrogate for genetic ancestry, and racial health disparities are driven largely by socioeconomic factors. The American Society of Nephrology and the National Kidney Foundation (ASN/NKF) recommend widespread adoption of new "race-free" creatinine equations, and increased use of cystatin C as a race-agnostic GFR biomarker. DATA SOURCES: Literature review and expert consensus. STUDY SELECTION: English language publications evaluating GFR assessment and racial disparities. DATA EXTRACTION: We provide an overview of the ASN/NKF recommendations. We then apply an Implementation science methodology to identify facilitators and barriers to implementation of the ASN/NKF recommendations into critical care settings and identify evidence-based implementation strategies. Last, we highlight research priorities for advancing GFR estimation in critically ill patients. DATA SYNTHESIS: Implementation of the new creatinine-based GFR equation is facilitated by low cost and relative ease of incorporation into electronic health records. The key barrier to implementation is a lack of direct evidence in critically ill patients. Additional barriers to implementing cystatin C-based GFR estimation include higher cost and lack of test availability in most laboratories. Further, cystatin C concentrations are influenced by inflammation, which complicates interpretation. CONCLUSIONS: The lack of direct evidence in critically ill patients is a key barrier to broad implementation of newly developed "race-free" GFR equations. Additional research evaluating GFR equations in critically ill patients and novel approaches to dynamic kidney function estimation is required to advance equitable GFR assessment in this vulnerable population. [ABSTRACT FROM AUTHOR]

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Re-engaging people with HIV who are newly out-of-care remains challenging. Data-to-care (D2C) is a potential strategy to re-engage such individuals. Methods: A prospective randomized controlled trial compared a D2C strategy using a disease intervention specialist (DIS) vs standard of care where 23 HIV clinics in 3 counties in Connecticut could re-engage clients using existing methods. Using a data reconciliation process to confirm being newly out-of-care, 655 participants were randomized to DIS (N = 333) or standard of care (N = 322). HIV care continuum outcomes included re-engagement at 90 days, retention in care, and viral suppression by 12 months. Multivariable regression models were used to assess factors predictive of attaining HIV care continuum outcomes. Results: Participants randomized to DIS were more likely to be re-engaged at 90 days (adjusted odds ratios [aOR] = 1.42, P = 0.045). Independent predictors of re-engagement at 90 days were age older than 40 years (aOR = 1.84, P = 0.012) and perinatal HIV risk category (aOR = 3.19, P = 0.030). Predictors of retention at 12 months included re-engagement at 90 days (aOR = 10.31, P < 0.001), drug injection HIV risk category (aOR = 1.83, P = 0.032), detectable HIV-1 RNA before randomization (aOR = 0.40, P = 0.003), and county (Hartford aOR = 1.74, P = 0.049; New Haven aOR = 1.80, P = 0.030). Predictors of viral suppression included re-engagement at 90 days (aOR = 2.85, P < 0.001), retention in HIV care (aOR = 7.07, P < 0.001), and detectable HIV-1 RNA prerandomization (aOR = 0.23, P < 0.001). Conclusions: A D2C strategy significantly improved re-engagement at 90 days. Early re-engagement improved downstream benefits along the HIV care continuum like retention in care and viral suppression at 12 months. Moreover, other factors predictive of care continuum outcomes can be used to improve D2C strategies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized steppedwedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56--79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40--2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58--80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47--7.78]; stroke centers (77.4%--90.0%); nonstroke centers [59.3%--72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41--35 minutes]; nonstroke centers [55--52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers. [ABSTRACT FROM AUTHOR]

Objective: While the design and clinical evidence base of robot-assisted gait training devices has been advancing, few studies investigate user experiences with accessing and using such devices in pediatric rehabilitation. This pilot study aims to further the understanding of barriers encountered by clinicians and caregivers when implementing a robot-assisted gait training device. Design: A qualitative descriptive study was conducted at a local outpatient pediatric therapy center with a robot-assisted gait training exoskeleton. Six caregivers and six clinicians participated in semistructured interviews with brief surveys. The surveys were summarized with descriptive statistics. The interviews were analyzed using directed content analysis guided by the Consolidated Framework for Implementation Research. Results: The five mostmentioned Consolidated Framework for Implementation Research constructswere knowledge and beliefs, relative advantage, child attributes, complexity, and access to knowledge and information. Caregivers experienced obstacles to accessing and trialing robot-assisted gait training devices. Clinicians expressed concerns regarding the feasibility of incorporating robot-assisted gait training into their clinic and preferred lower-tech gait training techniques. Conclusions: While some aspects of access and usability may be addressed by device design and technological advancements, overcoming other barriers will require a deeper understanding of the roles of scientific evidence, personal beliefs, and current therapy workflows in the uptake of robotic interventions. [ABSTRACT FROM AUTHOR]

Background: The progression of patients through a hospital from admission to discharge can be slowed by delays in patient discharge, increasing pressure on health care staff. We designed and piloted the Discharge Today tool, with the goal of improving the efficiency of patient discharge; however, adoption remained low. Purpose: To close this implementation gap, we deployed and evaluated a 4-part implementation strategy bundle. Methods: We measured the success of implementation by evaluating validated implementation outcomes using both quantitative and qualitative methods, grounded in Normalization Process Theory. Results: The implementation strategies used were effective for increasing use of the Discharge Today tool by hospital medicine physicians and advanced practice providers during both the active and passive implementation periods. Conclusions: While the implementation strategies used were effective, qualitative findings indicate that limitations in the functionality of the tool, alongside inconsistent use of the tool across clinical staff, continued to inhibit adoption. [ABSTRACT FROM AUTHOR]

Background: Despite strong evidence of improved patient outcomes, clinicians have been slow to adopt health literacy practices. Purpose: To identify facilitators and barriers to implementing health literacy practices into clinical care. Methods: Stakeholders (N = 40) completed surveys of acceptability, appropriateness, feasibility, conviction, and confidence with teach-back practices. Using the Consolidated Framework for Implementation Research (CFIR), interviews (n = 12) were conducted and analyzed. Results: Most reported high acceptability, appropriateness, and feasibility, but low confidence in using teach-back. Facilitators included leadership engagement and relative advantage. Barriers were related to compatibility due to time and workflow constraints. The CFIR-ERIC (Expert Recommendations for Implementing Change) Implementation Strategy Matching Tool was applied to select implementation strategies. Conclusions: The CFIR framework along with the CFIR-ERIC Matching Strategy Tool helped the research team select strategies likely to yield successful implementation and sustained use of health literacy practices. [ABSTRACT FROM AUTHOR]

School-based immunizations are fear-inducing events for many students and contribute to vaccine hesitancy. We developed an immunization delivery framework called the CARD (Comfort Ask Relax Distract) system that incorporates evidence-based interventions to improve the experience (eg, reduce fear, pain, dizziness). We evaluated CARD in grades 6 and 9 students in Calgary, Canada. In this pragmatic, hybrid, effectiveness-implementation, cluster trial, we randomized 8 Community Health Centres providing regional immunization services to CARD or control (usual care). In the CARD group, public health staff educated students about CARD and planned processes to reduce fear cues and support student coping choices during immunization. Students self-reported fear, pain, and dizziness during immunization using a 0-10 numerical rating scale; staff recorded procedure details, including vaccines administered, fainting episodes, and coping strategies used. Staff participated in focus groups afterward. Altogether, 8839 children from 105 schools in the 2019 to 2020 school calendar year were included. Fear was lower for CARD (mean = 3.6 [SD = 3.1] vs control 4.1 [3.2]; mean difference = −0.5; 95% confidence interval = −0.74 to −0.21; P < 0.001). Effectiveness persisted after stratification by student gender (male and female) and grade level (grade 6 and grade 9). Other symptoms did not differ. Compared with control, CARD students used peers, privacy, muscle tension, and topical anesthetics more; verbal distraction, deep breathing, and adult support were used less frequently (P < 0.05, all analyses). Immunization rate did not differ. Staff reported positive to neutral attitudes about CARD. In summary, this pragmatic trial demonstrated that CARD improved the immunization experiences of students at school. [ABSTRACT FROM AUTHOR]

This article explores the importance of rapid and intensive guideline-directed medical therapy (GDMT) for heart failure. It outlines five key principles for initiating and adjusting GDMT promptly, including the speed of initiation and in-hospital initiation. The article also emphasizes the benefits of GDMT for older and frail patients, the safety and tolerability of GDMT across different populations, and the potential risks of not implementing GDMT. It highlights the underutilization of GDMTs and calls for a shift in the traditional approach to GDMT for heart failure. The full study can be accessed using the provided DOI. [Extracted from the article]

Introduction and aims: Present-day home care needs to be more efficiently organized in view of the aging of the population and the current nursing shortages. Ensuring safe medication use is part of the challenge. The number of required visits could be reduced if automated home medication dispensers (AHMD) are adequately implemented. However, the barriers and facilitators for implementation are unknown. This project explored determinants (barriers, facilitators, or both) for implementing AHMD in home care, from Dutch home care nurses' perspective. Methods: Semi-structured interviews were conducted with 15 home care nurses. Determinants were identified through thematic content analysis. The first four transcripts were coded inductively. Then, a code tree was developed based on the Tailored Implementation for Chronic Diseases checklist, consisting of seven domains. Each code/determinant was then labelled as a barrier, facilitator, or both. Results: The most relevant domains were innovation factors, individual health professional factors, and patient factors. The most frequently mentioned barrier was the required unplanned visits when patients did not withdraw medication within the scheduled time limit (alarm). According to our respondents, carefully assessing patients' eligibility (e.g., learnability) and properly instructing and guiding them will help prevent these alarms from occurring. Next to these determinants, motivating patients to start using an AHMD and professionals having sufficient knowledge and confidence were the most frequently mentioned facilitators. Conclusion: This project provided an overview of 78 determinants from nurses' perspective for implementation of AHMD in home care. This can form the basis for developing strategies for implementing AHMD in home care. Further research is recommended to investigate the perceived determinants from the patients', relatives', and informal caregivers' perspectives, and to prioritize the determinants from all perspectives. [ABSTRACT FROM AUTHOR]

Introduction and aims: Considering that attitudes toward evidence-based dentistry (EBD) may predict implementation behaviors, the objective of this systematic review was to synthesize and evaluate the existing evidence related to dentists' attitudes and practices toward EBD. Methods: We included primary studies that collected information from interviews, questionnaires, or conversation sessions with dentists. The following sources were searched: Cochrane Central Register of Controlled Trials, Embase, PubMed, Scopus, and Web of Science, in addition to gray literature. The included studies were appraised according to the assessment tools recommended by JBI for qualitative and quantitative observational studies. Data were collected in standardized tables and descriptively synthesized. Results: The selection process resulted in 36 included studies. Dentists share positive opinions about EBD and predominantly report willingness to learn or adopt these practices. Despite high methodological risks and significant heterogeneity, the results collected in this review indicated that scientific journals, clinical practice guidelines, and trusted colleagues are generally perceived as influential and useful by dentists, who highly consulted these information sources. Conclusion: Despite supportive attitudes toward EBD, very low certainty exists about actual EBD-related practices. [ABSTRACT FROM AUTHOR]

Objective: The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care. Introduction: Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared with health care. Inclusion criteria: This review included studies of any design that examined the implementation of innovations in aged care settings. Methods: Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine eligibility. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories. Results: Of the 2530 studies that were screened, 193 were included. Of the included papers, 74% related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context, including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions, such as stakeholder engagement or implementation strategies. Conclusions: Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care and greater engagement with theory and community are needed to promote research rigor, relevance, and applicability. [ABSTRACT FROM AUTHOR]

Introduction: Post-operative pain is the most prevalent type of acute pain. Nurses are the health care professionals who most frequently assess pain, as well as evaluating the patient's response to pain management treatment and monitoring for the occurrence of adverse events. Thus, to improve outcomes and quality of care, the interventions used by nurses should be based on best practices. Objectives: The aim of this project was to implement best practices in post-operative pain management in an intensive care unit. Methods: This evidence implementation project was conducted in a hospital for the surgical treatment of orthopedic diseases and trauma. The project followed the JBI Evidence Implementation Framework. The project used JBI PACES software as well as JBI's Getting Research into Practice (GRiP) audit and feedback tools to develop eight audit criteria for the baseline and follow-up audits. Results: The baseline audit showed that Criteria 3 and 6 had low compliance, with few patients having documented plans and goals, and receiving multimodal analgesia in the ICU, respectively. Criteria 7 and 8, which assessed the use of opioids and follow-up by a pain specialist, revealed compliance of 60% and 50%, respectively. Criterion 3 improved from 0% to 20%. Criteria 6, 7, and 8 also improved, rising to 30%, 22.8%, and 50%, respectively. Conclusion: The project improved compliance with best practices in post-operative pain management. Further studies are needed to ensure the project's long-term sustainability. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI). Setting: Community. Participants: Healthcare providers (n = 63) with 2 or more years’ experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach. Design: Participatory-based research design, using descriptive and intervention mapping approaches. Results: Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence)based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change. Conclusion: Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice. [ABSTRACT FROM AUTHOR]

Objective: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. Setting: Community. Participants: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main Measures: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. Results: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. Conclusion: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI. [ABSTRACT FROM AUTHOR]

Objective: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework’s core domains of identifying a need, perceptions of the need, and seeking healthcare are reported. Setting: Community. Participants: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main Measures: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective. Results: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on)site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types. Conclusion: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care. [ABSTRACT FROM AUTHOR]

Background: Smartphone apps used in research offer a variety of capabilities to track and influence behavior; however, they often do not translate well into real-world use. Implementation strategies for using apps to reduce sedentary behavior in cardiac rehabilitation are currently unknown. Objective: The aim of this study was to explore (1) barriers and enablers for use of a behavioral smartphone app (Vire and ToDo-CR program) for reducing sedentary behavior in cardiac rehabilitation participants and (2) implementation strategies for future smartphone apps aimed at reducing sedentary behavior in this population. Methods: In-depth semistructured interviews were conducted with cardiac rehabilitation participants in the ToDo-CR randomized controlled trial. Participants had used the Vire app and a wearable activity tracker for 6 months. Interviews were audio recorded and transcribed. The researchers used thematic analysis and deductive mapping of themes to the Theoretical Domains Framework and the Capability, Opportunity, and Motivation-Behavior model. Sociodemographic and clinical variables were recorded. Results: Fifteen participants aged 59 ± 14 years were interviewed. Most were male, tertiary educated, and employed, and had varying experiences with smartphone apps and wearable activity trackers. Five core themes explaining the user experiences of cardiac rehabilitation participants with the Vire app were identified: (1) being tech savvy can be both an enabler and a barrier, (2) app messaging needs to be clear—set expectations from the beginning, (3) get to know me—personalization is important, (4) curious to know more instant feedback, and (5) first impression is key. The themes and subthemes mapped to 12 of the 14 Theoretical Domains Framework domains. Improving engagement and implementation of future smartphone apps for sedentary behavior may be aided by building psychological capability, physical opportunity, and reflective motivation. Conclusions: Shifting to in-the-moment behavioral nudges, setting clear expectations, assisting participants to monitor their sitting time, increasing the frequency of tailoring, and understanding more about the participant as well as their experiences and needs for reducing sedentary behavior in cardiac rehabilitation are important future directions. [ABSTRACT FROM AUTHOR]

Background: HIV self-testing (HIVST) can increase the reach of HIV testing. Preexposure prophylaxis (PrEP) clients may be ideal distributors of HIVST kits and PrEP information within their social networks. This study uses the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the distribution of HIVST bundled with PrEP information ("Test-to-PrEP" kits) among egocentric friendship networks of PrEP users. Methods: The study was conducted in Miami from November 2021 to March 2022. Enrolled PrEP clients (egos; n = 100) were offered Test-to- PrEP kits for distribution. Egos and Test-to-PrEP kit users completed brief online surveys. Descriptive statistics are reported for participants, their reported network members, and users of the Test-to-PrEP kits. Logistic and Poisson regression assessed the relationship between characteristics of egos, alters, and the distribution of Test-to-PrEP kits. Results: The 100 enrolled egos reported a total of 414 alters. Participants received 293 Test-to-PrEP kits for distribution with 47 of the 100 participants distributing at least 1 kit. Of those who scanned the quick-response code and responded to the survey, 16.2% reported no previous HIV test and 38.5% reported no prior knowledge of PrEP; 32.5% reported interest in distributing Test-to-PrEP kits, 3 successfully distributed kits, and 2 initiated PrEP. Conclusions: An approach using PrEP clients' social networks can disseminate HIVST bundled with PrEP information to critical populations including individuals lacking knowledge of PrEP or who have never been tested for HIV. Future studies will assess whether this use of network effects can increase reach and efficiency of HIV testing and PrEP information distribution. [ABSTRACT FROM AUTHOR]

Objectives: This project aimed to improve compliance with evidence-based practice in pain assessment and management in a gynecology ward. Introduction: Effective pain control is important to prevent the negative consequences of pain that is poorly managed. However, it remains undervalued and inadequately treated. Applying evidence-based practices to correctly evaluate and manage pain is essential to improve pain relief. Methods: This project followed the JBI Evidence Implementation Framework. A baseline audit of 41 women admitted to the gynecology ward was conducted and measured against 5 best practice criteria, along with a patient satisfaction questionnaire. Targeted strategies were then implemented and a follow-up audit was conducted using the same criteria, methods, and sample size as the baseline audit. Results: The baseline audit revealed gaps between current and best practice. Barriers to implementation were identified and strategies to resolve the barriers were designed and implemented (nurse education, informative materials, electronic patient records system improvements). Comprehensive pain assessment, including dynamic and static pain assessment, use of a validated tool, and education provided to patients and carers, improved in the follow-up audit. There was no change in patient satisfaction levels; however, the discrepancy between pain measured by nurses and pain measured by patients was reduced. Conclusions: The JBI methodology was useful in improving compliance with evidence-based practice criteria. It also facilitated adaptation to new barriers, such as the COVID-19 pandemic. Improving nurses' knowledge of pain assessment can lead to more accurate assessment. Inadequate records systems also made it difficult to record the care that was provided. Subsequent audits will assess sustainability and the project will be escalated to other wards. [ABSTRACT FROM AUTHOR]

A well-known challenge in health care is integrating evidence into practice. Implementation science (IS) is a growing field that promotes the sustainable application of evidence-based practice (EBP) to clinical care. Health care organizations have an opportunity to support sustainable change by creating robust IS infrastructures that engage nurses in the clinical environment. Integrating IS into a nursing shared governance model is an ideal vehicle to empower direct care nurses to sustain EBP. Importantly, an IS infrastructure may also promote nurse retention and increase interdisciplinary collaboration. This article, the first in a series on applying IS, describes how a multisite health care organization developed a systemwide nurse-led IS Specialist program within a shared governance model. This article, the first in a series, describes how a multisite health care organization developed a systemwide nurse-led Implementation Science Specialist program within a shared governance model. [ABSTRACT FROM AUTHOR]

There are many theories, models, and frameworks that have been proposed in the field of implementation science. Despite this, many evidence implementation or practice improvement projects do not consider these theories, models, or frameworks in their improvement efforts. The JBI approach is one example of an implementation theory, model, or framework. This approach has been developed particularly with health care professionals in mind and is designed to clearly guide pragmatic evidence implementation efforts based on the best available evidence. In this paper, we discuss how the JBI approach to evidence implementation can interact with and support theory-informed, pragmatic evidence implementation projects. [ABSTRACT FROM AUTHOR]

Background: The Bottom Up Project, a collaboration of clinical, community, and academic partners, consists of 7 major steps that leverage a health information exchange, a system for sharing patient health information, with real-time alerts to mobilize peer outreach workers to find and re-engage persons with HIV disconnected from care. Bottom Up faced implementation challenges in its start-up phase and produced effective responses leading to Project maturation, which we explore using a novel implementation science framework incorporating resilience. Methods: We conducted semistructured interviews with implementation staff (N = 6) and meeting minutes and protocols document reviews (N = 35). The Consolidated Framework for Implementation Research and a novel resilience framework guided thematic and process analyses. The resilience framework consisted of the following 3 resilience types: absorptive to cope with adversity, adaptive to adjust as short-term solutions, and transformative to structurally change. Results: The Project experienced 20 major challenges, 2-5 challenges per step. Challenges were multilevel and of chronic and crisis intensities. Implementers overcame challenges by leveraging multilevel factors that were absorptive, adaptive (most common), and transformative. Discussion: Bottom Up matured by practicing consistency and flexibility. The Project maintained core operations while under crisis-level stress by strategically simplifying or "downshifting" activities. Transformational responses suggest that specific initiatives can catalyze organizational change. Conclusions: Bottom Up implementation demonstrates using diverse tactics to respond to challenges, thereby shaping Project development and in turn organizations. Applying resilience to Consolidated Framework for Implementation Research helps build awareness of active and dynamic processes promoting or impeding the growth and success of intervention-oriented Projects. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Geriatric nurse practitioners (NPs) are introduced into health systems to alleviate provider shortages and improve care for older adults. To achieve these goals, geriatric NPs must be integrated into the health system such that they can efficaciously practice. Internationally, little is known about factors affecting the integration of NPs. Such evidence would improve policymaking and the impact of geriatric NPs on care. In Israel, geriatric NPs were recently introduced. Their ongoing integration is an exemplar for other countries. Purpose: To identify factors affecting the integration of geriatric NPs in Israel and discuss application of these factors in international policy and research. Methodology: The Consolidated Framework for Implementation Research guided this qualitative descriptive study. A semistructured interview guide was used to collect data from four professional groups (geriatric NPs, physicians, administrators, and policymakers), which, together, provide a system-level perspective. Factors were identified using deductive content analysis and designated as facilitators, barriers, neutral, or mixed effects. Results: There were 58 participants across the four professional groups. Twenty-eight factors were identified, including patient needs and leadership engagement (facilitators), available information (barrier), culture (mixed), and evidence strength (neutral). Perspectives on several factors differed by the professional group's role in integrating NPs (e.g., costs). Conclusions: The barriers highlight lacking interprofessional support from a priori policymaking and communication breakdowns. Policies should reflect priorities of administrators, clinicians, and policymakers. Implications: These factors may inform policymaking in other countries but would be most effective if based on country-specific research. This implementation science approach may inform future studies. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Prone positioning for acute respiratory distress syndrome (ARDS) has historically been underused, but was widely adopted for COVID-19-associated ARDS early in the pandemic. Whether this successful implementation has been sustained over the first 3 years of the COVID-19 pandemic is unknown. In this study, we characterized proning use in patients with COVID-19 ARDS from March 2020 to December 2022. DESIGN: Multicenter retrospective observational study. SETTING: Five-hospital health system in Maryland, USA. PATIENTS: Adults with COVID-19 supported with invasive mechanical ventilation and with a PaO2/FIO2 ratio of less than or equal to 150 mm Hg while receiving FIO2 of greater than or equal to 0.6 within 72 hours of intubation. INTERVENTIONS: None. MEASUREMENTS: We extracted demographic, clinical, and positioning data from the electronic medical record. The primary outcome was the initiation of proning within 48 hours of meeting criteria. We compared proning use by year with univariate and multivariate relative risk (RR) regression. Additionally, we evaluated the association of treatment during a COVID-19 surge period and receipt of prone positioning. MAIN RESULTS: We identified 656 qualifying patients; 341 from 2020, 224 from 2021, and 91 from 2022. More than half (53%) met severe ARDS criteria. Early proning occurred in 56.2% of patients in 2020, 56.7% in 2021, and 27.5% in 2022. This translated to a 51% reduction in use of prone positioning among patients treated in 2022 versus 2020 (RR = 0.49; 95% CI, 0.33-0.72; p < 0.001). This reduction remained significant in adjusted models (adjusted RR = 0.59; 95% CI, 0.42-0.82; p = 0.002). Treatment during COVID-19 surge periods was associated with a 7% increase in proning use (adjusted RR = 1.07; 95% CI, 1.02-1.13; p = 0.01). CONCLUSIONS: The use of prone positioning for COVID-19 ARDS is declining. Interventions to increase and sustain appropriate use of this evidence-based therapy are warranted. [ABSTRACT FROM AUTHOR]

Purpose: Health information exchange (HIE) improves healthcare quality, but is underutilized by providers. This study used a nationally representative survey of ambulatory physicians to examine barriers to HIE, and identify which barriers have the greatest impact on providers' use of HIE. Methods: A pooled sample of 1,292 physicians from the 2018-2019 National Electronic Health Record Survey was used. Univariate statistics described rates and patterns of eight common barriers to HIE. Multivariate logistic regression examined the relationship between each barrier and the use of HIE. Results: Barriers to HIE were common and diverse. Negative attitudes toward HIE's ability to improve clinical quality significantly decreased HIE use (OR 5 .44, p, .01). Conclusions: To increase adoption of HIE, efforts should focus on addressing providers' negative attitudes toward HIE. These findings can guide targeted implementation strategies to improve HIE adoption. [ABSTRACT FROM AUTHOR]

Background and Purpose: There is interest in incorporating digital health technology in routine practice. We integrate multiple stakeholder perspectives to describe implementation determinants (barriers and facilitators) regarding digital health technology use to facilitate exercise behavior change for people with Parkinson disease in outpatient physical therapy. Methods: The purposeful sample included people with Parkinson disease (n = 13), outpatient physical therapists (n = 12), and advanced technology stakeholders including researchers and reimbursement specialists (n = 13). Semistructured interviews were used to elicit implementation determinants related to using digital health technology for activity monitoring and exercise behavior change. Deductive codes based on the Consolidated Framework for Implementation Research were used to describe implementation determinants. Results: Key implementation determinants were similar across stakeholder groups. Essential characteristics of digital health technology included design quality and packaging, adaptability, complexity, and cost. Implementation of digital health technology by physical therapists and people with Parkinson disease was influenced by their knowledge, attitudes, and varied confidence levels in using digital health technology. Inner setting organizational determinants included available resources and access to knowledge/information. Process determinants included device interoperability with medical record systems and workflow integration. Outer setting barriers included lack of external policies, regulations, and collaboration with device companies. Discussion and Conclusions: Future implementation interventions should address key determinants, including required processes for how and when physical therapists instruct people with Parkinson disease on digital health technology, organizational readiness, workflow integration, and characteristics of physical therapists and people with Parkinson disease who may have ingrained beliefs regarding their ability and willingness to use digital health technology. Although site-specific barriers should be addressed, digital health technology knowledge translation tools tailored to individuals with varied confidence levels may be generalizable across clinics. [ABSTRACT FROM AUTHOR]

Successful organizations depend on strategic thinkers who understand strategic planning and strategic management. These strategic leaders can proactively manage the constant environmental changes to position their organizations for a competitive advantage and avoid acting in a reactive and defensive manner. However, while organizations are often adept at developing extensive strategic plans, implementation of the plan is often poor or without a definitive strategy. This article addresses key strategies for successful implementation of changes to bring about sustainable cultural change in an organization to meet the organization's overall strategic goals, specifically through the use of implementation science. [ABSTRACT FROM AUTHOR]

Introduction and aims: Excess gestational weight gain is a challenge within antenatal care. Low-intensity interventions that offer opportunities for individualization, such as pregnancy weight-gain charts (PWGCs) combined with brief advice, have been a promising strategy but scaling out such interventions requires planning. The aim of this study was to examine current practices and conduct a context assessment using the Consolidated Framework for Implementation Research (CFIR) to guide implementation of PWGCs and brief intervention advice to support healthy pregnancy weight gain in two hospitals that provide antenatal care. Methods: Retrospective chart audits and surveys of staff and women were used to understand current practice as well as barriers and enablers to implementing change according to the domains and constructs reported in the CFIR. Results: Forty-eight percent (site A) and 46% (site B) of pregnant women who were audited (n=180, site A; n=176, site B) gained weight above recommendations. Most women were unable to accurately report their recommended weight gain for pregnancy (93% site A, 94% site B). Although more than 50% of women reported discussions about weight gain during pregnancy, advice about physical activity and healthy eating (in the context of helping women to achieve healthy gestational weight gain) was low. Mapping barriers and enablers to the CFIR helped guide the selection of implementation strategies, including audit and feedback, informing local opinion leaders, obtaining consensus, identifying champions, and building a coalition. Conclusion: Scaling out of interventions can be enhanced by undertaking a detailed context assessment guided by implementation frameworks. [ABSTRACT FROM AUTHOR]

This document discusses the challenges and benefits of implementing low-dose anticoagulant use in patients with peripheral artery disease (PAD). The article highlights the prevalence and seriousness of PAD, as well as the underutilization of guideline-recommended therapies. The VOYAGER PAD and COMPASS trials have provided evidence supporting the use of low-dose anticoagulation in PAD patients, particularly those who have undergone endovascular revascularization procedures. The article emphasizes the need for further research, safety studies, and implementation efforts to ensure the effective use of low-dose anticoagulants in clinical practice. Additionally, barriers such as high drug prices and prescriber behavior are discussed, and potential interventions to increase anticoagulation use are suggested. [Extracted from the article]

Supplemental Digital Content is Available in the Text. Background: HIV pre-exposure prophylaxis (PrEP) delivery at private pharmacies is a promising new differentiated service delivery model that may address barriers to PrEP delivery at public health care facilities. We measured the fidelity of this model (ie, delivery as intended) in a pilot study in Kenya. Setting: Five private, retail pharmacies in Kisumu and Thika Counties. Methods: Trained pharmacy providers delivered PrEP services, including identifying eligible clients, counseling on HIV risk, assessing PrEP safety, testing for HIV, and dispensing PrEP. Pharmacy clients completed surveys that assessed the fidelity of the services received after each visit. Standardized client actors (ie, mystery shoppers) were trained on 4 different case scripts, then made unannounced pharmacy visits, and then completed a 40-item checklist that assessed the fidelity and quality of service delivery components. Results: From November 2020 to December 2021, 287 clients initiated and 159 (55%) refilled PrEP. At initiation, most clients were counseled on PrEP adherence (99%, 284 of 287) and potential side effects (97%, 279 of 287) and all received provider-assisted HIV self-testing before PrEP dispensing (findings consistent across refill visits). Nine standardized client actors completed 15 pharmacy visits. At each visit, most actors were asked about their behaviors associated with HIV risk (80%, 12/15) and all were counseled on PrEP safety and side effects. All actors reported that pharmacy providers treated them with respect. Conclusions: In this first pilot study of pharmacy-delivered PrEP services in Africa, the fidelity of service delivery was high, suggesting that trained providers at private pharmacies can deliver quality PrEP services. [ABSTRACT FROM AUTHOR]

Objective: Although concussions affect millions of young adults annually, researchers have yet to assess factors that may affect future implementation of post-concussion academic supports within higher education. Therefore, we sought to evaluate preimplementation outcomes of the acceptability, feasibility, appropriateness, and readiness for change of the Post-Concussion Collegiate Return-to-Learn (RTL) Protocol among university stakeholders. Setting: An online survey. Participants: A convenience sample (N = 49; 63.3% female) of athletic trainers (ATs; n = 25, age = 30.1 ± 7.6 years) and university faculty/staff (n = 24, age = 38.3 ± 9.9 years) across the National Collegiate Athletic Association (NCAA) Power 5 Conferences from January to February 2022. Design: A cross-sectional study. Main Measures: To compare preimplementation outcome measures using the Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM), Intervention Appropriateness Measure (IAM), and Organizational Readiness for Implementing Change (ORIC) regarding the RTL protocol between ATs and university faculty/staff. Additional outcomes included internal and external barriers to implementing at their respective institutions. Statistical analyses were conducted using Mann-Whitney U tests, with effect sizes estimated using eta-squared coefficient (η2). Results: Quantitative analyses yielded no statistically significant group differences (P s >.05) across the AIM, FIM, and IAM outcomes, indicating both groups perceived the protocol to be acceptable, feasible, and appropriate. Moreover, ATs reported higher agreement regarding motivation, desire, willingness to do "whatever it takes," commitment, and determination to implement the novel protocol than faculty/staff. Further, ATs reported higher agreement regarding their institution's confidence to keep track of its progress, support adjustment, maintain momentum, manage institutional politics, coordinate tasks, encourage investment, and handle the challenges of future implementation of the RTL protocol. Conclusions: Preliminary findings suggest ATs and university faculty/staff across the NCAA Power 5 Conferences may perceive the RTL protocol to be acceptable, feasible, and appropriate for future use; however, noteworthy internal and external barriers may influence its uptake. Future research should utilize implementation frameworks to support the protocol's adoption and reach. [ABSTRACT FROM AUTHOR]

Introduction: Globally, there is an increasing incidence of chronic diseases, particularly, diabetes. Patient engagement in disease self-management is essential to improve outcomes and reduce consumption of health resources. Despite investment in this area, there is a need to improve nursing care practices. Aims: To increase compliance of Endocrinology nurses with best practice in promoting self-management of diabetes by patients. Methods: The project was conducted in an Endocrinology unit of a Portuguese central hospital. It was based on the JBI's model approach, considering three phases: baseline audit, strategy design and implementation, and follow-up audit. For the audits, 11 criteria were considered. The sample was composed of patients (15 in the baseline; 30 at the follow-up audit), and nurses (15 in both audits). Results: The baseline audit showed that there was poor compliance in some criteria. Four barriers were identified and the strategies/resources to mitigate them. There was improvement in all audit criteria as the project developed (100% compliance in seven criteria; two criteria increased from 0 to 100%). Conclusion: The evidence-based implementation project improved nursing practices for self-management planning of the person with diabetes. The adequacy of the strategies developed should be highlighted, namely the training and reflection on practices. The creation of the standardized discharge procedure has also improved compliance (criteria 7–10). The culture of patient-centred care, the desire to provide quality care, the involvement of the nurse manager, informal leaders, and the support office for information and documentation systems in nursing were facilitators in this process. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. Summary Background Data: Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. Methods: We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. Results: Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. Conclusions: There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: To address challenges with delivery of an evidence-based HIV care coordination program (CCP), the New York City Health Department initiated a CCP redesign. We conducted a site-randomized stepped-wedge trial to evaluate effectiveness of the revised versus the original model. Setting: The CCP is delivered in New York City hospitals, community health centers, and community-based organizations to people experiencing or at risk for poor HIV outcomes. Methods: The outcome, timely viral suppression (TVS), was defined as achievement of viral load <200 copies/mL within 4 months among enrollees with unsuppressed viral load (≥200 copies/mL). Seventeen original-CCP provider agencies were randomized within matched pairs to early (August 2018) or delayed (May 2019) starts of revised-model implementation. Data from 3 periods were examined to compare revised versus original CCP effects on TVS. The primary analysis of the intervention effect applied fully conditional maximum likelihood estimation together with an exact, conditional P -value and an exact test-based 95% CI. We assigned each trial enrollee the implementation level of their site (based on a three-component measure) and tested for association with TVS, adjusting for period and study arm. Results: Over 3 nine-month periods, 960 individuals were eligible for trial inclusion (intention to treat). The odds ratio of TVS versus no TVS comparing revised with original CCP was 0.88 (95% CI: 0.45, 1.7). Thus, the revised program yielded slightly lower TVS, although the effect was statistically nonsignificant. TVS was not significantly associated with revised-CCP implementation level. Conclusion: Program revisions did not increase TVS, irrespective of the implementation level. [ABSTRACT FROM AUTHOR]

Senior nurse leaders are accountable for improving patient outcomes efficiently and cost-effectively. Nurse leaders often find heterogeneous patient outcomes across comparable nursing units in the same enterprise, presenting a challenge for nurse leaders tasked with making system-wide quality improvements. Implementation science (IS) offers a promising new approach to guide nurse leaders in understanding why certain implementation efforts meet with success or failure and the barriers faced in making practice changes. Knowledge of IS builds upon evidenced-based practice and quality improvement knowledge, adding to the armamentarium of tools at nurse leaders' disposal for improving nursing and patient outcomes. In this article, we demystify IS, differentiate it from evidence-based practice and quality improvement, describe IS concepts every nurse leader should be familiar with, and outline nurse leaders' role in building IS in their organizations. [ABSTRACT FROM AUTHOR]

Routine implementation and sustainability of evidence-based practices (EBPs) into health care is often the most difficult stage in the change process. Despite major advances in implementation science and quality improvement, a persistent 13- to 15-year research-to-practice gap remains. Nurse leaders may benefit from tools to support implementation that are based on scientific evidence and can be readily integrated into complex health care settings. This article describes development and evaluation of an evidence-based implementation and sustainability toolkit used by health care clinicians seeking to implement EBPs. For this project, implementation science and EBP experts created initial iterations of the toolkit based on Rogers' change theory, the Advancing Research through Close Collaboration (ARCC) model, and phases and strategies from implementation science. Face validity and end-user feedback were obtained after piloting the tool with health care clinicians participating in immersive EBP sessions. The toolkit was then modified, with subsequent content validity and usability evaluations conducted among implementation science experts and health care clinicians. This article presents the newly updated Fuld Institute Evidence-based Implementation and Sustainability Toolkit for health care settings. Nurse leaders seeking to implement EBPs may benefit from an evidence-based toolkit to provide a science-informed approach to implementation and sustainability of practice changes. [ABSTRACT FROM AUTHOR]

In this paper, we provide an overview of JBI's approach to evidence implementation and describe the supporting process model that aligns with this approach. The central tenets of JBI's approach to implementing evidence into practice include the use of evidence-based audit and feedback, identification of the context in which evidence is being implemented, facilitation of any change, and an evaluation process. A pragmatic and practical seven-phased approach is outlined to assist with the ‘planning’ and ‘doing’ of getting evidence into practice, focusing on clinicians as change agents for implementing evidence in clinical and policy settings. Further research and development is required to formally evaluate the robustness of the approach to better understand the complex nature of evidence implementation. [ABSTRACT FROM AUTHOR]

Background: We designed and implemented an enhanced model of integrating family planning (FP) into existing HIV treatment services at 6 health facilities in Lusaka, Zambia. Methods: The enhanced model included improving FP documentation within HIV monitoring systems, training HIV providers in FP services, offering contraceptives within the HIV clinic, and facilitated referral to community-based distributors. Independent samples of women living with HIV (WLHIV) aged ≥16 years were interviewed before and after intervention and their clinical data abstracted from medical charts. Logistic regression models were used to assess differences in key outcomes between the 2 periods. Results: A total of 629 WLHIV were interviewed preintervention and 684 postintervention. Current FP use increased from 35% to 49% comparing the pre- and postintervention periods (P = 0.0025). Increased use was seen for injectables (15% vs. 25%, P < 0.0001) and implants (5% vs. 8%, P > 0.05) but not for pills (10% vs. 8%, P < 0.05) or intrauterine devices (1% vs. 1%, P > 0.05). Dual method use (contraceptive + barrier method) increased from 8% to 18% (P = 0.0003), whereas unmet need for FP decreased from 59% to 46% (P = 0.0003). Receipt of safer conception counseling increased from 27% to 39% (P < 0.0001). The estimated total intervention cost was $83,293 (2018 USD). Conclusions: Our model of FP/HIV integration significantly increased the number of WLHIV reporting current FP and dual method use, a met need for FP, and safer conception counseling. These results support continued efforts to integrate FP and HIV services to improve women's access to sexual and reproductive health services. [ABSTRACT FROM AUTHOR]

Background: The Doctor of Nursing Practice (DNP) project is the culmination of DNP education, serving as evidence of knowledge preparation and skill achievement in translating evidence into practice. Problem: Review of sample DNP projects from 2015 to 2019 revealed that multiple projects had fatal flaws in the Methods and Evaluation sections, rendering the resulting DNP project with diminished value. Approach: We established a collaborative relationship with an educational statistics program and associated consulting center to develop and integrate statistical resources directly into the planning and evaluating stages of the DNP project process. The pilot program included workshops and individual consulting sessions provided to the student aimed at reducing fatal flaws and improving research design and evaluation analyses. Outcomes: Initial and follow-up surveys were adapted from the Course Experience Questionnaire to assess student satisfaction and perceived knowledge gains. Project rigor and value were assessed using the DNP-Project Critical Appraisal Tool (PCAT). Conclusions: The pilot program showed a decrease in the number of fatal flaws and an increase in PCAT scores on the targeted Design and Evaluation sections. [ABSTRACT FROM AUTHOR]

Design, implementation, and evaluation of effective multicomponent interventions typically take decades before value is realized even when value can be measured. Value-based health care, an approach to improving patient and health system outcomes, is a way of organizing health systems to transform outcomes and achieve the highest quality of care and the best possible outcomes with the lowest cost. We describe 2 case studies of value-based health care optimized through a learning health system framework that includes Strategic Clinical Networks. Both cases demonstrate the acceleration of evidence to practice through scientific, financial, structural administrative supports and partnerships. Clinical practice interventions in both cases, one in perioperative services and the other in neonatal intensive care, were implemented across multiple hospital sites. The practical application of using an innovation pipeline as a structural process is described and applied to these cases. A value for money improvement calculator using a benefits realization approach is presented as a mechanism/tool for attributing value to improvement initiatives that takes advantage of available system data, customizing and making the data usable for frontline managers and decision makers. Health care leaders will find value in the descriptions and practical information provided. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Daily oral pre-exposure prophylaxis (PrEP) adherence is challenging. We explored African adolescent girls and young women's (AGYW) perceptions of the social influencers of their PrEP use and the social influencers' PrEP knowledge and support (six focus group discussions; 33 South African and Kenyan AGYW) in the Prevention Options for Women Evaluation Research demonstration project. Participants completed a social mapping exercise indicating strength and direction of influence of members in their social networks. Mothers and counselors were identified as positive influencers and most influential by >50% of participants, sex partners were labeled negative influencers or both positive and negative, and best friends were mostly positive influencers. HIV- and PrEP-related stigma were the major reasons influencers were identified as negative. Participants wanted their social networks to be better educated about PrEP by someone other than the AGYW themselves (e.g., clinic staff) and to support their PrEP use. To improve PrEP adherence, community- and peer-based PrEP sensitization and delivery interventions should be evaluated. [ABSTRACT FROM AUTHOR]

During the past few years, several innovative treatments for noncommunicable chronic disease have become available, including SGLT2i (sodium-glucose cotransporter-2 inhibitors), GLP-1a (glucagon-like-peptide 1 agonists), ARNI (angiotensin receptor-neprilysin inhibitors), and finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist. Each of these medications improves clinically relevant outcomes when added to existing therapies, and the indications for their use are rapidly expanding. Because existing drug regimens are already complex and costly, ensuring that society derives the maximal benefit from these new agents represents a major challenge. This Primer discusses how society can meet this challenge, which we address in terms of 5 principles: maximizing benefit, minimizing harm, optimizing uptake, increasing value for money, and ensuring equitable access. The Primer is most relevant for stakeholders in high-income countries, but the principles are broadly applicable to stakeholders in other settings, including low- and middle-income countries. We have focused the discussion on SGLT-2i, but the 5 principles herein could be used with reference to ARNI, finerenone, or any other health product. [ABSTRACT FROM AUTHOR]

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities. [ABSTRACT FROM AUTHOR]