HSR&D Center for Clinical Management Research, VA Ann Arbor Health Care System (11H), Ann Arbor, MI, USA.
Implement Sci. 2010 Dec 30;5:99. doi: 10.1186/1748-5908-5-99.
Along with the increasing prevalence of chronic illness has been an increase in interventions, such as nurse case management programs, to improve outcomes for patients with chronic illness. Evidence supports the effectiveness of such interventions in reducing patient morbidity, mortality, and resource utilization, but other studies have produced equivocal results. Often, little is known about how implementation of an intervention actually occurs in clinical practice. While studies often assume that interventions are used in clinical practice exactly as originally designed, this may not be the case. Thus, fidelity of an intervention's implementation reflects how an intervention is, or is not, used in clinical practice and is an important factor in understanding intervention effectiveness and in replicating the intervention in dissemination efforts. The purpose of this paper is to contribute to the understanding of implementation science by (a) proposing a methodology for measuring fidelity of implementation (FOI) and (b) testing the measure by examining the association between FOI and intervention effectiveness.
We define and measure FOI based on organizational members' level of commitment to using the distinct components that make up an intervention as they were designed. Semistructured interviews were conducted among 18 organizational members in four medical centers, and the interviews were analyzed qualitatively to assess three dimensions of commitment to use--satisfaction, consistency, and quality--and to develop an overall rating of FOI. Mixed methods were used to explore the association between FOI and intervention effectiveness (inpatient resource utilization and mortality).
Predictive validity of the FOI measure was supported based on the statistical significance of FOI as a predictor of intervention effectiveness. The strongest relationship between FOI and intervention effectiveness was found when an alternative measure of FOI was utilized based on individual intervention components that had the greatest variation across medical centers.
In addition to contextual factors, implementation research needs to consider FOI as an important factor in influencing intervention effectiveness. Our proposed methodology offers a systematic means for understanding organizational members' use of distinct intervention components, assessing the reasons for variation in use across components and organizations, and evaluating the impact of FOI on intervention effectiveness.
随着慢性病患病率的增加，护士病例管理等干预措施也有所增加，以改善慢性病患者的结局。证据支持这些干预措施在降低患者发病率、死亡率和资源利用方面的有效性，但其他研究结果却不一致。通常，人们对干预措施在临床实践中的实际实施情况知之甚少。虽然研究通常假设干预措施在临床实践中是按照最初的设计使用的，但情况可能并非如此。因此，干预措施实施的保真度反映了干预措施在临床实践中是如何被使用的，或者没有被使用，这是理解干预措施有效性和在传播工作中复制干预措施的一个重要因素。本文的目的是通过（a）提出一种测量实施保真度（FOI）的方法，以及（b）通过检查 FOI 与干预效果之间的关联来测试该方法，为实施科学的理解做出贡献。
我们根据组织成员对使用构成干预措施的独特组件的承诺程度来定义和衡量 FOI，这些组件是按照设计使用的。在四个医疗中心的 18 名组织成员中进行了半结构化访谈，并对访谈进行了定性分析，以评估使用承诺的三个维度——满意度、一致性和质量——并制定 FOI 的总体评分。混合方法用于探索 FOI 与干预效果（住院资源利用和死亡率）之间的关联。
基于 FOI 作为干预效果预测因子的统计学显著性，支持了 FOI 测量的预测效度。当使用基于医疗中心之间变化最大的各个干预组件的替代 FOI 测量时，FOI 与干预效果之间的关系最强。
除了背景因素外，实施研究还需要考虑 FOI 作为影响干预效果的一个重要因素。我们提出的方法为理解组织成员使用不同干预组件提供了一种系统的方法，评估了组件和组织之间使用差异的原因，并评估了 FOI 对干预效果的影响。
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