Tracking Implementation Strategies in the Randomized Rollout of a Veterans Affairs National Opioid Risk Management Initiative

Abstract

Background: In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete ‘case reviews’ for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids.. Half of facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. Methods: Facility points of contact completed a survey assessing their facility’s use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews.Results: Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR: 16-31) strategies. The median case review completion rate was 71% (IQR: 48%-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were: using the STORM dashboard (97%); working with local opinion leaders (80%); and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being <35 years old (incidence rate ratio, IRR: 1.35, 95%CI: 1.09-1.67) and having <5 years in their primary role (IRR: 1.23; 95%CI: 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR: 1.40, 95%CI: 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included: 1) monitoring and adjusting practices (adjusted IRR, (AIRR): 1.40, 95%CI: 1.11-1.77), 2) identifying adaptations while maintaining core components (AIRR: 1.28, 95%CI: 1.03-1.60), 3) conducting initial training (AIRR: 1.16, 95%CI: 1.02-1.50), and 4) regularly sharing lessons learned (AIRR: 1.32, 95%CI: 1.09-1.59). Conclusions: In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not.Trial registration: This project is registered at the ISRCTN Registry with number ISRCTN16012111 (URL: http://www.isrctn.com/ISRCTN16012111). The trial was first registered on 5/3/2017.

Integrating implementation science in clinical research to maximize public health impact: a call for the reporting and alignment of implementation strategy use with implementation outcomes in clinical research

“…We draw from existing efforts to prospectively and retrospectively track and report implementation strategies within implementation research. Rogal and colleagues [33][34][35] surveyed implementation practitioners regarding their use of ERIC strategies to promote various health behaviors such as hepatitis C virus medication adherence. Importantly, Rogal and colleagues found that it was feasible to present stakeholders with the list of ERIC strategies and that stakeholders were able to reliably select the ones they used.…”

“…As the field of implementation science has matured, it has become quite clear that organizations often need to deploy many implementation strategies to successfully implement an intervention (e.g., [33,38]). For example, in Rogal's [33][34][35] aforementioned work, between 23 and 27 implementation strategies were used to support the health interventions. Reporting the implementation strategies used is only one component of a multi-item reporting checklist (e.g., item 9 of StaRI's 27 item checklist).…”

“…Additional file 1 provides an example of what we believe to be such a pragmatic tool. Given Rogal et al's [33] work that demonstrates that it is feasible to provide the entire list of ERIC strategies to non-implementation scientists and have them reliably select which ones they used, the pragmatic implementation strategy reporting tool combines the ERIC taxonomy [25] with Proctor and colleagues' [8] guidelines for implementation strategy reporting. Presseau and colleagues' [27] AACTT model was originally designed to clarify and specify behaviors that makeup implementation outcomes and implementation strategies are similarly clusters of behaviors.…”

Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration

“…Academic detailing is an effective educational outreach strategy commonly used to impact care in this patient population by targeting uptake of evidence-based practice at the provider level [30,36]. Academic detailing [30,36] and other approaches [21,37] designed to promote uptake of evidence-based practice could benefit from this rapid, developmental approach to tailoring implementation strategies to fit the complex and dynamic interaction between the clinical innovation (M-OUD), recipients, and context. Our mixed methods analysis of 6-month outcomes helps us to understand whether implementation interventions and strategies can make meaningful change in facility metrics quickly to, ultimately, impact patient outcomes.…”

Getting to implementation: a protocol for a Hybrid III stepped wedge cluster randomized evaluation of using data-driven implementation strategies to improve cirrhosis care for Veterans

“…Moreover, many of the "evidence-based" implementation strategies that we have identified in similar projects are inherent to GTO (Table 2). These include providing facilitation, designating implementation leaders, site visits, developing an implementation blueprint, developing an interdisciplinary clinical team, and sharing lessons learned, audit and feedback, quality monitoring and adjusting practices accordingly, and tailoring while maintaining fidelity [21,47]. We anticipate that aim 1 may identify strategies that are not inherent to GTO.…”