A stakeholder-driven method for selecting implementation strategies: a case example of pediatric hypertension clinical practice guideline implementation

Abstract

Background This article provides a generalizable method, rooted in co-design and stakeholder engagement, to identify, specify, and prioritize implementation strategies. To illustrate this method, we present a case example focused on identifying strategies to promote pediatric hypertension (pHTN) Clinical Practice Guideline (CPG) implementation in community health center-based primary care practices that involved meaningful engagement of pediatric clinicians, clinic staff, and patients/caregivers. This example was chosen based on the difficulty clinicians and organizations experience in implementing the pHTN CPG, as evidenced by low rates of guideline-adherent pHTN diagnosis and treatment. Methods We convened a Stakeholder Advisory Panel (SAP), comprising 6 pediatricians and 5 academic partners, for 8 meetings (~12 h total) to rigorously identify determinants of pHTN CPG adherence and to ultimately develop a testable multilevel, multicomponent implementation strategy. Our approach expanded upon the Expert Recommendations for Implementation Change (ERIC) protocol by incorporating a modified Delphi approach, user-centered design methods, and the Implementation Research Logic Model (IRLM). At the recommendation of our SAP, we gathered further input from youth with or at-risk for pHTN and their caregivers, as well as clinic staff who would be responsible for carrying out facets of the implementation strategy. Results First, the SAP identified 17 determinants, and 18 discrete strategies were prioritized for inclusion. The strategies primarily targeted determinants in the domains of intervention characteristics, inner setting, and characteristics of the implementers. Based on SAP ratings of strategy effectiveness, feasibility, and priority, three tiers of strategies emerged, with 7 strategies comprising the top tier implementation strategy package. Next, input from caregivers and clinic staff confirmed the feasibility and acceptability of the implementation strategies and provided further detail in the definition and specification of those strategies. Conclusions This method—an adaptation of the ERIC protocol—provided a pragmatic structure to work with stakeholders to efficiently identify implementation strategies, particularly when supplemented with user-centered design activities and the intuitive organizing framework of the IRLM. This generalizable method can help researchers identify and prioritize strategies that align with the implementation context with an increased likelihood of adoption and sustained use.

Correlates of Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics: A Two-Year Cross-Sectional Study

“…For example, a stakeholder advisory panel comprising AllianceChicago pediatricians and academic partners identified 18 discrete implementation strategies needed to improve adherence to the 2017 CPG, including education and training, workflow changes, and leadership support. 19…”

“…16,17 Numerous barriers to appropriate pHTN diagnosis and management have been identified, including high patient volumes and short visit times in primary care; low confidence in BP readings due to poor measurement technique or inadequate equipment; and lack of appropriate follow-up by patients. 18,19 A common strategy employed to try to overcome these barriers is the use of clinical decision support (CDS) tools in the EHR to save time and decrease clinician decision-making burden, and have been shown to improve recognition of pHTN. 20,21 To date, most studies examining pHTN guideline adherence, as well as use of CDS tools, have been conducted using the guidelines in the Fourth Report.…”

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia

“…Using implementation research methods to inform the evidence synthesis using narrative review and formative assessment helped us better identify the challenges and provide an initial understanding of the conceptual links between determinants, implementation strategies, mechanisms, and outcomes. The use of concept mapping is essential in informing the choice of implementation strategies and is associated with more effective implementation [ 26 , 37 ]. Stakeholder engagement and co-creation have been identified as key steps in designing and implementing complex interventions such as treatment for PSBI [ 26 , 47 ].…”

“…The Implementation Research Logic Model (IRLM) combines a number of commonly used IR frameworks to help design or evaluate the implementation of evidence-based interventions by identifying determinants and selection strategies through mapping mechanisms and linking those implementation and effectiveness outcomes [ 25 ]. There is also emerging evidence from the United States that IRLM is an effective tool for stakeholder engagement critical for success in implementation work [ 26 ], but not in Ethiopia or similar settings.…”

Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics

“…They also used a multistep approach including a literature review to identify determinants of implementation, [26]. Knapp et al (2022) provides another useful method of how to meaningfully engage stakeholders to identify and specify implementation strategies [38].…”