Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA.
Department of Public Health, Zuckerberg School of Health Sciences, University of Massachusetts, Lowell, MA, USA.
BMC Health Serv Res. 2023 Nov 22;23(1):1282. doi: 10.1186/s12913-023-10245-9.
Shared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening.
We conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).
We tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening.
Formative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.
美国医疗保险和医疗补助服务中心要求进行“共享决策”，以讨论肺癌筛查的获益和危害与患者价值观的一致性，多个组织也对此进行了推荐。组织、临床医生、临床就诊和患者层面的障碍使“共享决策”无法在常规实践中达到质量标准。我们使用社会生态模型，为退伍军人事务部（VA）新英格兰医疗保健系统制定了肺癌筛查的“共享决策”实施计划。由于了解当地情况对实施成功至关重要，我们试图主动调整我们的原始实施计划，以解决实现指南一致的肺癌筛查的障碍。
我们使用民族志方法进行了形成性评估，以主动识别“共享决策”的障碍并调整我们的实施计划。数据包括对来自 VA 新英格兰七个医疗中心的领导层和临床医生的定性访谈、区域会议记录以及临床医生使用的“共享决策”脚本和文件。调整是根据报告适应和修改循证实施策略的框架（FRAME-IS）进行的。
我们调整了原始实施计划，以解决我们在组织、临床医生、临床就诊和患者层面发现的障碍。总体而言，我们取消了两项实施策略，增加了五项策略，并修改了两项策略的内容。例如，在临床医生层面，我们了解到过去的个人和临床经验使临床医生倾向于关注肺癌筛查的获益。为了解决这个障碍，我们修改了我们原始实施策略“使培训具有活力”的内容，以促使提供者自我反思他们的筛查信念和价值观，鼓励他们讨论肺癌筛查的获益和潜在危害。
形成性评估可用于主动调整实施策略以适应当地情况。我们调整了我们的实施计划，以解决我们发现的独特障碍，目标是提高实施的成功率。FRAME-IS 帮助我们的团队深思熟虑地处理和修改我们的原始实施计划。其他希望最大限度地提高复杂干预措施有效性的人可能会考虑使用类似的方法。
