Authors:
Vera Yakovchenko, Chaeryon Kang, Brittney Neely, Carolyn Lamorte, Heather McCurdy, Dawn Scott, Anna Nobbe, Gwen Robins, Nsikak R. Ekanem, Monica Merante, Sandra Gibson, Patrick Spoutz, Linda Chia, Rachel I. Gonzalez, Matthew J. Chinman, David Ross, Maggie Chartier, Lauren A. Beste, Jasmohan S. Bajaj, Tamar Taddei, Timothy R. Morgan & Shari S. Rogal
University of Washington affiliated authors are displayed in bold.
✪ Open Access
Published: December 2025
Read the full text in the open access journal Implementation Science
Abstract:
Background
While guidelines recommend twice-yearly liver cancer (hepatocellular carcinoma, HCC) surveillance for people with cirrhosis, adherence to these guidelines remains variable. We aimed to empirically identify and apply successful implementation strategies through Getting to Implementation (GTI), a manualized facilitation approach.
Method
A hybrid type III, stepped-wedge, cluster-randomized trial was conducted at 12 underperforming Veterans Health Administration (VA) sites between October 2020 and October 2022. GTI included a stepwise approach to guide sites to detail their current state, set implementation goals, identify implementation barriers, select implementation strategies, make a work plan, conduct an evaluation, and sustain their work. Outcomes were defined using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.
Results
Facilitators supported site teams with an average of 20±6 facilitation hours over a 12-month period. Ten of 12 sites (83%) adopted GTI and applied a median of five strategies (e.g., dashboard use, small tests of change, direct patient outreach). Reach, the primary outcome, increased from mean 29.1% to mean 38.8% at-risk Veterans receiving HCC surveillance from pre- to post-intervention, and further increasing to 41.3% in the sustainment period. In both unadjusted and adjusted models, the odds of HCC surveillance were significantly higher during intervention (adjusted odds ratio, aOR=1.67, 95% CI:1.59, 1.75) and during sustainment (aOR=1.69, 95% CI:1.60, 1.78) compared with baseline, and with difference between active and sustainment periods, indicating sustained improvement after active facilitation ended.
Conclusions
GTI sustainably improved HCC surveillance, suggesting that applying data-driven implementation strategies within a manualized facilitation approach can improve care.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**