Dopp Alex R, Hindmarch Grace, Chan Osilla Karen, Meredith Lisa S, Manuel Jennifer K, Becker Kirsten, Tarhuni Lina, Schoenbaum Michael, Komaromy Miriam, Cassells Andrea, Watkins Katherine E
RAND Corporation, USA.
Stanford University, USA.
Evid Policy. 2024 Feb;20(1):15-35. doi: 10.1332/17442648Y2023D000000016. Epub 2024 Jan 8.
Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange.
We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs).
We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors.
Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic.
Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.
在服务系统中实施循证实践（EBPs）对于改善人群健康至关重要，但也具有挑战性，尤其是在资源匮乏环境中实施复杂的行为健康干预措施时。“实施不当”是指循证实践实施工作产生的不良结果；实施不当的结果是有关如何改善知识交流的重要但在很大程度上未被利用的信息来源。
我们展示了在美国联邦合格健康中心（FQHCs）进行的三项行为健康循证实践务实试验中的实施不当案例。
我们将实施研究综合框架及其结果附录改编为实施不当框架，并使用该框架构建案例摘要，其中包含有关循证实践和试验、实施不当结果以及相关决定因素（障碍和促进因素）的信息。我们比较了这三个案例，以确定共同和独特的实施不当因素。
在各个案例中，干预措施的采用和保真度有限，最终导致干预措施中断。导致实施不当 的障碍包括干预措施的复杂性、负担过重的提供者参与度低、提供者与领导层之间缺乏一致性以及与 COVID-19 相关的压力源。在同时经历患者和提供者层面障碍且在 COVID-19 大流行期间进行的案例中，实施不当出现得更早。
多层次决定因素导致了联邦合格健康中心循证实践的实施不当，限制了这些卫生系统从知识交流中获益的能力。为了尽量减少实施不当，知识交流策略应围绕常见的核心障碍进行设计，但也要足够灵活，以应对各种特定地点的背景因素，并应针对提供者、患者和/或领导层等相关受众进行量身定制。
