Cara C. Lewis Archives - Implementation Science at UW

✪ Theorizing is for everybody: Advancing the process of theorizing in implementation science

Abstract:

There has been a call to shift from treating theories as static products to engaging in a process of theorizing that develops, modifies, and advances implementation theory through the accumulation of knowledge. Stimulating theoretical advances is necessary to improve our understanding of the causal processes that influence implementation and to enhance the value of existing theory.

We argue that a primary reason that existing theory has lacked iteration and evolution is that the process for theorizing is obscure and daunting. We present recommendations for advancing the process of theorizing in implementation science to draw more people in the process of developing and advancing theory.

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✪ Mediators of measurement-based care implementation in community mental health settings: results from a mixed-methods evaluation

Abstract:

Background

Tailored implementation approaches are touted as superior to standardized ones with the reasoning that tailored approaches afford opportunities to select strategies to resolve determinants of the local context. However, results from implementation trials on this topic are equivocal. Therefore, it is important to explore relevant contextual factors that function as determinants to evaluate if they are improved by tailoring and subsequently associated with changes in implementation outcomes (i.e., via statistical mediation) to better understand how tailoring achieves (or does not achieve) its effects. The present study examined the association between a tailored and standardized implementation approach, contextual factors that might mediate change, and a target implementation outcome in an initiative to implement measurement-based care (specifically the clinical integration of the Patient Health Questionnaire [PHQ-9] for depression) in a community mental health organization.

Methods

Using a cluster randomized control design, twelve community-based mental health clinics were assigned to a tailored or standardized implementation group. Clinicians completed a self-report battery assessing contextual factors that served as candidate mediators informed by the Framework for Dissemination at three time points: baseline, 5 months after active implementation support, and 10 months after sustainment monitoring. A subset of clinicians also participated in focus groups at 5 months. The routine use of the PHQ-9 (implementation outcome) was monitored during the 10-month sustainment period. Multi-level mediation analyses assessed the association between the implementation group and contextual factors and the association between contextual factors and PHQ-9 completion. Quantitative results were then elaborated by analyzing qualitative data from exemplar sites

Results

Although tailored clinics outperformed standard clinics in terms of PHQ-9 completion at the end of active implementation, these group differences disappeared post sustainment monitoring. Perhaps related to this, no significant mediators emerged from our quantitative analyses. Exploratory qualitative analyses of focus group content emphasized the importance of support from colleagues, supervisors, and leadership when implementing clinical innovations in practice.

Conclusions

Although rates of PHQ-9 completion improved across the study, their sustained levels were roughly equivalent across groups and low overall. No mediators were established using quantitative methods; however, several partial quantitative pathways, as well as themes from the qualitative data, reveal fruitful areas for future research.

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✪ Measuring readiness for implementation: A systematic review of measures’ psychometric and pragmatic properties

Abstract:

Background

Systematic measure reviews can facilitate advances in implementation research and practice by locating reliable, valid, pragmatic measures; identifying promising measures needing refinement and testing; and highlighting measurement gaps. This review identifies and evaluates the psychometric and pragmatic properties of measures of readiness for implementation and its sub-constructs as delineated in the Consolidated Framework for Implementation Research: leadership engagement, available resources, and access to knowledge and information.

Methods

The systematic review methodology is described fully elsewhere. The review, which focused on measures used in mental or behavioral health, proceeded in three phases. Phase I, data collection, involved search string generation, title and abstract screening, full text review, construct assignment, and cited citation searches. Phase II, data extraction, involved coding relevant psychometric and pragmatic information. Phase III, data analysis, involved two trained specialists independently rating each measure using Psychometric and Pragmatic Evidence Rating Scales (PAPERS). Frequencies and central tendencies summarized information availability and PAPERS ratings.

Results

Searches identified 9 measures of readiness for implementation, 24 measures of leadership engagement, 17 measures of available resources, and 6 measures of access to knowledge and information. Information about internal consistency was available for most measures. Information about other psychometric properties was often not available. Ratings for internal consistency were “adequate” or “good.” Ratings for other psychometric properties were less than “adequate.” Information on pragmatic properties was most often available regarding cost, language readability, and brevity. Information was less often available regarding training burden and interpretation burden. Cost and language readability generally exhibited “good” or “excellent” ratings, interpretation burden generally exhibiting “minimal” ratings, and training burden and brevity exhibiting mixed ratings across measures.

Conclusion

Measures of readiness for implementation and its sub-constructs used in mental health and behavioral health care are unevenly distributed, exhibit unknown or low psychometric quality, and demonstrate mixed pragmatic properties. This review identified a few promising measures, but targeted efforts are needed to systematically develop and test measures that are useful for both research and practice.

Plain language abstract

Successful implementation of effective mental health or behavioral health treatments in service delivery settings depends in part on the readiness of the service providers and administrators to implement the treatment; the engagement of organizational leaders in the implementation effort; the resources available to support implementation, such as time, money, space, and training; and the accessibility of knowledge and information among service providers about the treatment and how it works. It is important that the methods for measuring these factors are dependable, accurate, and practical; otherwise, we cannot assess their presence or strength with confidence or know whether efforts to increase their presence or strength have worked. This systematic review of published studies sought to identify and evaluate the quality of questionnaires (referred to as measures) that assess readiness for implementation, leadership engagement, available resources, and access to knowledge and information. We identified 56 measures of these factors and rated their quality in terms of how dependable, accurate, and practical they are. Our findings indicate there is much work to be done to improve the quality of available measures; we offer several recommendations for doing so.

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✪ Measuring implementation outcomes: An updated systematic review of measures’ psychometric properties

Abstract:

Background

Systematic reviews of measures can facilitate advances in implementation research and practice by locating reliable and valid measures and highlighting measurement gaps. Our team completed a systematic review of implementation outcome measures published in 2015 that indicated a severe measurement gap in the field. Now, we offer an update with this enhanced systematic review to identify and evaluate the psychometric properties of measures of eight implementation outcomes used in behavioral health care.

Methods

The systematic review methodology is described in detail in a previously published protocol paper and summarized here. The review proceeded in three phases. Phase I, data collection, involved search string generation, title and abstract screening, full text review, construct assignment, and measure forward searches. Phase II, data extraction, involved coding psychometric information. Phase III, data analysis, involved two trained specialists independently rating each measure using PAPERS (Psychometric And Pragmatic Evidence Rating Scales).

Results

Searches identified 150 outcomes measures of which 48 were deemed unsuitable for rating and thus excluded, leaving 102 measures for review. We identified measures of acceptability (N = 32), adoption (N = 26), appropriateness (N = 6), cost (N = 31), feasibility (N = 18), fidelity (N = 18), penetration (N = 23), and sustainability (N = 14). Information about internal consistency and norms were available for most measures (59%). Information about other psychometric properties was often not available. Ratings for internal consistency and norms ranged from “adequate” to “excellent.” Ratings for other psychometric properties ranged mostly from “poor” to “good.”

Conclusion

While measures of implementation outcomes used in behavioral health care (including mental health, substance use, and other addictive behaviors) are unevenly distributed and exhibit mostly unknown psychometric quality, the data reported in this article show an overall improvement in availability of psychometric information. This review identified a few promising measures, but targeted efforts are needed to systematically develop and test measures that are useful for both research and practice.

Plain language abstract

When implementing an evidence-based treatment into practice, it is important to assess several outcomes to gauge how effectively it is being implemented. Outcomes such as acceptability, feasibility, and appropriateness may offer insight into why providers do not adopt a new treatment. Similarly, outcomes such as fidelity and penetration may provide important context for why a new treatment did not achieve desired effects. It is important that methods to measure these outcomes are accurate and consistent. Without accurate and consistent measurement, high-quality evaluations cannot be conducted. This systematic review of published studies sought to identify questionnaires (referred to as measures) that ask staff at various levels (e.g., providers, supervisors) questions related to implementation outcomes, and to evaluate the quality of these measures. We identified 150 measures and rated the quality of their evidence with the goal of recommending the best measures for future use. Our findings suggest that a great deal of work is needed to generate evidence for existing measures or build new measures to achieve confidence in our implementation evaluations.

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What Gets Measured Gets Done: How Mental Health Agencies can Leverage Measurement-Based Care for Better Patient Care, Clinician Supports, and Organizational Goals

✪ A systematic review of empirical studies examining mechanisms of implementation in health

Abstract:

Background

Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms.

Methods

We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms “mechanism,” “mediator,” or “moderator.” Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality.

Results

Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms.

Conclusions

Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.

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Using implementation science to close the gap between the optimal and typical practice of quantitative methods in clinical science

Pragmatic measures for implementation research: development of the Psychometric and Pragmatic Evidence Rating Scale (PAPERS)

Testing and Exploring the Limits of Traditional Notions of Fidelity and Adaptation in Implementation of Preventive Interventions

✪ Operationalizing the ‘pragmatic’ measures construct using a stakeholder feedback and a multi-method approach

Abstract:

Context

Implementation science measures are rarely used by stakeholders to inform and enhance clinical program change. Little is known about what makes implementation measures pragmatic (i.e., practical) for use in community settings; thus, the present study’s objective was to generate a clinical stakeholder-driven operationalization of a pragmatic measures construct.

Evidence acquisition

The pragmatic measures construct was defined using: 1) a systematic literature review to identify dimensions of the construct using PsycINFO and PubMed databases, and 2) interviews with an international stakeholder panel (N = 7) who were asked about their perspectives of pragmatic measures.

Evidence synthesis

Combined results from the systematic literature review and stakeholder interviews revealed a final list of 47 short statements (e.g., feasible, low cost, brief) describing pragmatic measures, which will allow for the development of a rigorous, stakeholder-driven conceptualization of the pragmatic measures construct.

Conclusions

Results revealed significant overlap between terms related to the pragmatic construct in the existing literature and stakeholder interviews. However, a number of terms were unique to each methodology. This underscores the importance of understanding stakeholder perspectives of criteria measuring the pragmatic construct. These results will be used to inform future phases of the project where stakeholders will determine the relative importance and clarity of each dimension of the pragmatic construct, as well as their priorities for the pragmatic dimensions. Taken together, these results will be incorporated into a pragmatic rating system for existing implementation science measures to support implementation science and practice.

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✪ Open Access

Read the full text in the open access journal Frontiers in Health Services

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✪ Open Access

Read the full text in the open access journal Implementation Science

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Background

Methods

Results

Conclusions

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✪ Open Access

Read the full text in the open access journal Implementation Research and Practice

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Background

Methods

Results

Conclusion

Plain language abstract

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✪ Open Access

Read the full text in the open access journal Implementation Research and Practice

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Background

Methods

Results

Conclusion

Plain language abstract

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Read the full text in the subscription access journal Administration and Policy in Mental Health and Mental Health Services Research

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✪ Open Access

Read the full text in the open access journal Implementation Science

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Background

Methods

Results

Conclusions

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Read the full text in the subscription access Journal of Abnormal Psychology

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Read the full text in the subscription access journal Translational Behavioral Medicine

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Read the full text in the open access journal BMC Health Services Research

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Context

Evidence acquisition

Evidence synthesis

Conclusions