开发一个大规模实施他汀类药物选择交流辅助工具的工具包：工作简化模型的应用

Developing a toolkit to implement the Statin Choice Conversation Aid at scale: application of a work reduction model.

作者信息

Leppin Aaron L, Boehmer Kasey R, Branda Megan E, Shah Nilay D, Hargraves Ian, Dick Sara, Elwyn Glyn, Ting Henry H, Ye Siqin, Gilles Ryan, Abbas Marghoob, Alexander Alex, Montori Victor M

机构信息

Division of Health Care Policy and Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

出版信息

BMC Health Serv Res. 2019 Apr 24;19(1):249. doi: 10.1186/s12913-019-4055-8.

DOI:10.1186/s12913-019-4055-8

PMID:31018840

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6480421/

Abstract

BACKGROUND

Guidelines recommend shared decision making (SDM) for determining whether to use statins to prevent cardiovascular events in at-risk patients. We sought to develop a toolkit to facilitate the cross-organizational spread and scale of a SDM intervention called the Statin Choice Conversation Aid (SCCA) by (i) assessing the work stakeholders must do to implement the tool; and (ii) orienting the resulting toolkit's components to communicate and mitigate this work.

METHODS

We conducted multi-level and mixed methods (survey, interview, observation, focus group) characterizations of the contexts of 3 health systems (n = 86, 84, and 26 primary care clinicians) as they pertained to the impending implementation of the SCCA. We merged the data within implementation outcome domains of feasibility, appropriateness, and acceptability. Using Normalization Process Theory, we then characterized and categorized the work stakeholders did to implement the tool. We used clinician surveys and IP address-based tracking to calculate SCCA usage over time and judged how stakeholder effort was allocated to influence outcomes at 6 and 18 months. After assessing the types and impact of the work, we developed a multi-component toolkit.

RESULTS

At baseline, the three contexts differed regarding feasibility, acceptability, and appropriateness of implementation. The work of adopting the tool was allocated across many strategies in complex and interdependent ways to optimize these domains. The two systems that allocated the work strategically had higher uptake (5.2 and 2.9 vs. 1.1 uses per clinician per month at 6 months; 3.8 and 2.1 vs. 0.4 at 18 months, respectively) than the system that did not. The resulting toolkit included context self-assessments intended to guide stakeholders in considering the early work of SCCA implementation; and webinars, EMR integration guides, video demonstrations, and an implementation team manual aimed at supporting this work.

CONCLUSIONS

We developed a multi-component toolkit for facilitating the scale-up and spread of a tool to promote SDM across clinical settings. The theory-based approach we employed aimed to distinguish systems primed for adoption and support the work they must do to achieve implementation. Our approach may have value in orienting the development of multi-component toolkits and other strategies aimed at facilitating the efficient scale up of interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02375815 .

摘要

背景

指南推荐采用共同决策（SDM）来确定是否使用他汀类药物预防高危患者的心血管事件。我们试图开发一套工具包，以促进一种名为他汀类药物选择交流辅助工具（SCCA）的SDM干预措施在跨组织间的推广和扩大，具体方式为：（i）评估利益相关者为实施该工具必须开展的工作；（ii）使最终工具包的组件能够传达并减轻此项工作。

方法

我们对3个卫生系统（分别有86名、84名和26名初级保健临床医生）在即将实施SCCA时的情况进行了多层次混合方法（调查、访谈、观察、焦点小组）描述。我们将数据合并到可行性、适宜性和可接受性等实施结果领域。然后，运用规范化过程理论，我们对利益相关者为实施该工具所做的工作进行了描述和分类。我们利用临床医生调查和基于IP地址的跟踪来计算SCCA随时间的使用情况，并判断在6个月和18个月时利益相关者为影响结果所投入的努力情况。在评估了工作的类型和影响后，我们开发了一个多组件工具包。

结果

在基线时，这三种情况在实施的可行性、可接受性和适宜性方面存在差异。采用该工具的工作以复杂且相互依存的方式分配到多种策略中，以优化这些领域。与未进行战略分配的系统相比，两个进行战略分配的系统采用率更高（6个月时，分别为每位临床医生每月5.2次和2.9次，而另一个系统为1.1次；18个月时，分别为3.8次和2.1次vs 0.4次）。最终的工具包包括旨在指导利益相关者考虑SCCA实施前期工作的情境自我评估；以及旨在支持此项工作的网络研讨会、电子病历集成指南、视频演示和实施团队手册。