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Implementation Science at UW

Archives: UW Articles

✪ A phased approach to implementing the Breast Imaging Reporting and Data System (BI‐RADS) in low‐income and middle‐income countries

Authors:

Diana L. Lam, Pegah Entezari, Catherine Duggan, Zeridah Muyinda, Andres Vasquez, Jorge Huayanay, Benjamin O. Anderson, & John R. Scheel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI‐RADS), to improve system performance. In low‐income and middle‐income countries, evolving diagnostic programs have insufficient resources to either fully implement BI‐RADS or to periodically evaluate the program's performance, which is a necessary component of BI‐RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance.

Methods

The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI‐RADS within the context of a limited‐resource setting.

Results

The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI‐RADS should occur after performance and quality metrics have been met.

Conclusions

Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples

Authors:

Anne F. Rositch, Karla Unger‐Saldaña, Rebecca J. DeBoer, Anne Ng’ang’a, & Bryan J. Weiner

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence‐based interventions and/or practices into real‐world contexts. D&IS methods are useful for selecting strategies to implement evidence‐based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly.

Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence‐based, resource‐stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence‐based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline‐concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co‐creation is critical.

In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Situational analysis of breast health care systems: Why context matters

Authors:

Catherine Duggan, Allison Dvaladze, John R. Scheel, Lisa M. Stevens, & Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

Implementation of evidence‐based, resource‐appropriate guidelines for breast cancer control should be preceded by a baseline assessment or situational analysis to assess breast health infrastructure, workforce capacity, patient pathways, existing practices, accessibility, and costs.

Methods

To support the assessment of breast health care systems within the broader context in which they exist, the Breast Health Global Initiative (BHGI) developed, tested, and refined a set of situational analysis tools with which to guide the assessment of breast health care capacity, identify the relative strengths and weaknesses of the health system, and support stakeholders in prioritizing actionable items to advance breast cancer care using evidence‐based strategies tailored to their setting. The tools address 6 domains of breast health care delivery: 1) breast cancer early detection practices; 2) breast cancer awareness programs; 3) the availability of breast cancer surgery; 4) the availability of pathology; 5) the availability of radiotherapy, and 6) the availability of systemic therapy services. The current study also describes the more comprehensive International Atomic Energy Agency Programme of Action for Cancer Therapy (PACT) integrated missions for PACT (imPACT) review.

Results

As of 2020, 5 formal BHGI situational analyses have been performed in India, Brazil, Panama, Tanzania, and Uganda. As of August 2019, a total of 100 imPACT reviews have been conducted in 91 countries. These assessments can contribute to more informed policymaking.

Conclusions

Situational analyses are a prerequisite for the development of resource‐appropriate strategies with which to advance breast cancer control in any setting and should assess services across the entire breast health care continuum as well as the broader structural, sociocultural, personal, and financial contexts within which they operate.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Breast cancer treatment: A phased approach to implementation

Authors:

Miriam Mutebi, Benjamin O. Anderson, Catherine Duggan, Clement Adebamowo, Gaurav Agarwal, Zipporah Ali, Peter Bird, Jean‐Marc Bourque, Rebecca DeBoer, Luiz Henrique Gebrim, Riccardo Masetti, Shahla Masood, Manoj Menon, Gertrude Nakigudde, Anne Ng’ang’a, Nixon Niyonzima, Anne F. Rositch, Karla Unger‐Saldaña, Cynthia Villarreal‐Garza, Allison Dvaladze, Nagi S. El Saghir, Julie R. Gralow, and Alexandru Eniu

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low‐ and middle‐income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited‐resource settings by creating roadmaps that are individualized and adapted to the baseline environment.

This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late‐stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements.

A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1‐stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource‐Stratified Phased Implementation: Methods and overview

Authors:

Catherine Duggan, Allison Dvaladze, Anne F. Rositch, Ophira Ginsburg, Cheng‐Har Yip, Susan Horton, Rolando Camacho Rodriguez, Alexandru Eniu, Miriam Mutebi, Jean‐Marc Bourque, Shahla Masood, Karla Unger‐Saldaña, Anna Cabanes, Robert W. Carlson, Julie R. Gralow, and Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

The Breast Health Global Initiative (BHGI) established a series of resource‐stratified, evidence‐based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice.

Methods

In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource‐Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation ) for guiding the translation of resource‐appropriate breast cancer control guidelines into real‐world practice. Three expert consensus panels developed stepwise, resource‐appropriate recommendations for implementing these guidelines in low‐income and middle‐income countries as well as underserved communities in high‐income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening.

Results

Key findings from the summit and subsequent article preparation included the identification of phased‐implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real‐world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits.

Conclusions

Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Breast cancer early detection: A phased approach to implementation

Authors:

Ophira Ginsburg, Cheng‐Har Yip, Ari Brooks, Anna Cabanes, Maira Caleffi, Jorge Antonio, Dunstan Yataco, Bishal Gyawali, Valerie McCormack, Myrna McLaughlin de Anderson, Ravi Mehrotra, Alejandro Mohar, Raul Murillo, Lydia E. Pace, Electra D. Paskett, Anya Romanoff, Anne F. Rositch, John R. Scheel, Miriam Schneidman, Karla Unger‐Saldaña, Verna Vanderpuye, Tsu‐Yin Wu, Safina Yuma, Allison Dvaladze, Catherine Duggan, and Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource‐stratified guidelines for the early detection and diagnosis of breast cancer.

In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting.

Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real‐world settings are considered.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study

Authors:

Craig S. Rosen
C. Adrian Davis, David Riggs, Jeffery Cook, Alan L. Peterson, Stacey Young-McCaughan, Katherine Anne Comtois, Christopher K. Haddock, Elisa V. Borah, Katherine A. Dondanville, Erin P. Finley, Sara A. Jahnke, Walker S.C. Poston, Shannon Wiltsey-Stirman, Andrea Neitzer, Capt Rachel Broussard, MAJ Amy Brzuchalski, Maj Spencer P. Clayton, LT Allison M. Conforte, Araceli Flores, Jessica Hein, Capt Felicia Keith, Capt Jeremy Jinkerson, Margaret Letendre, Debra Nofziger, Kirsten Pollick, Capt Kyra Santiago, Lt Col John Waggoner, Craig Woodworth, and Carmen P. McLean for the STRONG STAR Consortium andthe TACTICS Research Group

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: April 2020

Read the full text in the subscription access journal Contemporary Clinical Trials

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

Authors:

Cara C. Lewis, Meredith R. Boyd, Callie Walsh-Bailey, Aaron R. Lyon, Rinad Beidas, Brian Mittman, Gregory A. Aarons, Bryan J. Weiner, & David A. Chambers

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Implementation Science

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.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ A targeted systematic review of cost analyses for implementation of simulation-based education in healthcare

Authors:

Daniel S Hippe, Rachel A Umoren, Alex McGee, Sherri L Bucher, Brian W Bresnahan

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2020

Read the full text in the open access journal SAGE Open Medicine

Abstract:

Over the past two decades, there has been an increase in the use of simulation-based education for training healthcare providers in technical and non-technical skills. Simulation education and research programs have mostly focused on the impact on clinical knowledge and improvement of technical skills rather than on cost. To study and characterize existing evidence to inform multi-stakeholder investment decisions, we performed a systematic review of the literature on costs in simulation-based education in medicine in general and in neonatal resuscitation as a particular focus.

We conducted a systematic literature search of the PubMed database using two targeted queries. The first searched for cost analyses of healthcare simulation-based education more broadly, and the second was more narrowly focused on cost analyses of neonatal resuscitation training. The more general query identified 47 qualified articles. The most common specialties for education interventions were surgery (51%); obstetrics, gynecology, or pediatrics (11%); medicine, nursing, or medical school (11%); and urology (9%), accounting for over 80% of articles. The neonatal resuscitation query identified five qualified articles. The two queries identified seven large-scale training implementation studies, one in the United States and six in low-income countries. There were two articles each from Tanzania and India and one article each from Zambia and Ghana. Methods, definitions, and reported estimates varied across articles, implying interpretation, comparison, and generalization of program effects are challenging.

More work is needed to understand the costs, processes, and outcomes likely to make simulation-based education programs cost-effective and scalable. To optimize return on investments in training, assessing resource requirements, associated costs, and subsequent outcomes can inform stakeholders about the potential sustainability of SBE programs. Healthcare stakeholders and decision makers will benefit from more transparent, consistent, rigorous, and explicit assessments of simulation-based education program development and implementation costs in low- and high-income countries.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**