Archives for June 2016

RE-AIM Framework Used in PTSD Study

By Rhiannon Iorio June 30th, 2016

Implementation science uses a variety of theoretical frameworks to help design interventions. The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework encourages program planners  to pay attention to the various elements of a program in order to sustain the implementation of an effective intervention. RE-AIM begins by helping researchers define their target population. This framework then looks at how an intervention can impact a specific outcome. To translate research into action, the intervention must be adopted by those initiating it. From there, this model examines the fidelity of the implementation to the intervention’s protocol. The last stepof the model is to maintain the interventions impact. Recently, this framework has been used to integrate trial results into a routine trauma center practice. The goal of the “trauma survivors’ outcomes and support (TSOS) effectiveness-implementation hybrid trial” is to test the delivery of a screening and intervention for PTSD across 24 US level 1 trauma sites. Click here to read more about implementation science and the RE-AIM framework used in this study.

For more information on the RE-AIM framework, visit our Theoretical Model Resources page.


Promoting the Use of the Consolidated Framework for Implementation Research (CFIR)

By Rhiannon Iorio June 27th, 2016

The Consolidated Framework for Implementation Research (CFIR) is used frequently in implementation research. This framework assesses both potential barriers and facilitators to implementing an intervention successfully. The evaluation of projects focuses on intervention characteristics, outer setting such as peer pressure and patient needs, inner setting such as culture and implementation climate, individual characteristics, and process. The process of CFIR follows a cycle constructed of planning, engaging, executing, and reflecting with evaluation.  CFIR is applied to an implementation depending on the kind of evaluation. We see CFIR used in implementation research when we develop data collection guides and interpret/report our findings. When used correctly, this framework can guide the formation of a research project and help it excel.

The article A systematic review of the use of the Consolidated Framework for Implementation Research examines peer-reviewed articles that use the CFIR framework in a meaningful way. The article provides specific recommendations for applying the CFIR constructs, implementing the framework during the implementation process, and understanding how to use CFIR depending on the phase of the research. 


To read more about using CFIR in implementation science, click here


Using Implementation Plans in WHO Guidelines

By Rhiannon Iorio June 20th, 2016

Implementation plans are created through evidence-based techniques that are proven to be effective. These plans can lead researchers to solve complex problems in healthcare all over the world. The World Health Organization (WHO) has adopted some implementation plans into its guidelines for recommendations for clinical practice and public health. The WHO guidelines are followed by many to solve complex problems, and including implementation science is critical to ensure successful interventions. Research is being conducted on the amount of implementation science included in the WHO guidelines, and how closely the WHO follows the framework. A study called The Implementation Plans included in World Health Organizations recently conducted an analysis of the implementation sections of the WHO guidelines to assess if the methods are evidence based. The focus of this study is to describe plans for guideline implementation included in the WHO guidelines from 2007-2015 and concludes with valuable recommendations for the WHO.


Click here to read about the study


Operational Research Joins Implementation Science

By Rhiannon Iorio June 15th, 2016

Thomas Monk (2016) describes how operational research (OR) and implementation science can be woven together to achieve a common goal-to solve problems. In healthcare, we utilize both methods to find solutions, such as how to reduce hospital readmissions or how to decrease patient wait times.  Although operations and implementation work toward a common goal, they each take a unique approach. OR professionals create models that forecast relationships, use statistical analysis, and implement various allocation strategies. This research focuses heavily on advanced analytical methods, and is a necessary step to encourage the decision making process in implementation strategies. Implementation science uses various methods to integrate research findings into healthcare and focuses on testing new approaches to improve healthcare delivery. Implementation science also examines the relationship between the intervention and the results. The role of OR in implementation science has been up for debate, but if fused together, researchers would use both mathematical and social strategies to create an effective solution to a complex healthcare problem.

Below is an abstract from Thomas Monk’s article Operational Research as implementation science: definitions, challenges and research priorities


Operational research (OR) is the discipline of using models, either quantitative or qualitative, to aid decision-making in complex implementation problems. The methods of OR have been used in healthcare since the 1950s in diverse areas such as emergency medicine and the interface between acute and community care; hospital performance; scheduling and management of patient home visits; scheduling of patient appointments; and many other complex implementation problems of an operational or logistical nature.


To date, there has been limited debate about the role that operational research should take within implementation science. I detail three such roles for OR all grounded in upfront system thinking: structuring implementation problems, prospective evaluation of improvement interventions, and strategic reconfiguration. Case studies from mental health, emergency medicine, and stroke care are used to illustrate each role. I then describe the challenges for applied OR within implementation science at the organisational, interventional, and disciplinary levels. Two key challenges include the difficulty faced in achieving a position of mutual understanding between implementation scientists and research users and a stark lack of evaluation of OR interventions. To address these challenges, I propose a research agenda to evaluate applied OR through the lens of implementation science, the liberation of OR from the specialist research and consultancy environment, and co-design of models with service users.


Operational research is a mature discipline that has developed a significant volume of methodology to improve health services. OR offers implementation scientists the opportunity to do more upfront system thinking before committing resources or taking risks. OR has three roles within implementation science: structuring an implementation problem, prospective evaluation of implementation problems, and a tool for strategic reconfiguration of health services. Challenges facing OR as implementation science include limited evidence and evaluation of impact, limited service user involvement, a lack of managerial awareness, effective communication between research users and OR modellers, and availability of healthcare data. To progress the science, a focus is needed in three key areas: evaluation of OR interventions, embedding the knowledge of OR in health services, and educating OR modellers about the aims and benefits of service user involvement.

To learn more about operational research as implementation science click here 


A Tool to Reduce Readmissions at BMC

By Rhiannon Iorio June 3rd, 2016

Originally found in the BMC Brief: 

What happens to our patients when they leave the hospital? Sometimes we see them at clinics, sometimes we never see them again, but too many end up back in the hospital within 30 days. Hospitals are traditionally set up to care for patients during an acute episode, but preventing readmissions can be an important part of care, both for positive patient outcomes and for the hospital’s performance on quality metrics tied to funding. As a result, a team at BMC is working to create a hospital-wide strategy for preventing readmissions.

“In some ways it may seem counterintuitive to try to keep people out of the hospital,” says Carrie Solomon, Senior Manager of Strategy Implementation. “But we’re a whole system, not just the hospital, and we want to care for the whole patient, not just an acute care episode. Some people who come in are just sick, but many have other issues that drive health problems, and we can utilize primary care, specialty care, other hospital programs, and community resources to help keep people from needing acute care.”

BMC is working on a hospital-wide strategy to reduce unnecessary readmissions that seeks to address the complex clinical and psychosocial issues that many at-risk patients face, such as homelessness or substance use disorders. BMC’s readmissions rate has been trending down due to the work departments have been doing to prevent readmissions, and the hospital has made it a priority to continue this downward trend. Performance on readmissions is tied to $15 million in funding from the state and federal government, but reducing readmissions is also important to help BMC prepare for upcoming policy changes.

“While there are currently some penalties for readmission rates, we know health reform is coming,” says Alexandra Yurkovic, MD, Medical Director of Strategy Implementation. “The reality is that up until now, each readmission was more money for the hospital, but when there’s a Medicaid accountable care organization, things will be very different, and keeping people out of the hospital will be a priority. But what this really means is that financial incentives are catching up with what feels clinically right – to keep our patients as healthy as possible.”

Solomon and Yurkovic worked with BMC’s data analytics team to pinpoint the biggest drivers of readmission, based on a year’s worth of BMC patient data, and identified 14 key factors. Those factors are used to calculate a score – in real-time – for every patient admitted to an adult medical inpatient unit. The scores are displayed in eMERGE patient charts upon admission so that providers and ancillary services can identify patients at the highest risk of 30-day readmissions and focus targeted interventions and resources where they will make the biggest difference.

Patients are segmented into four groups, with a focus on the two most at-risk cohorts: super utilizers, who represent five percent of admissions and have a 63 percent chance of being readmitted, and high-risk patients, who represent 15 percent of admissions and have a 54 percent chance of being readmitted. Moderate risk patients, who represent 30 percent of admissions and have a 17 percent chance of being readmitted, will receive lower-touch interventions such as post-discharge phone calls.

Super utilizers and high risk patients receive high-touch interventions to help reduce readmission rates. An inpatient pharmacist meets with each patient to conduct a patient interview focusing specifically on medication history and medication reconciliation. A social worker also meets with each patient to perform a psychosocial evaluation to find out what non-medical issues could lead to a patient’s readmission. In addition, an order set will come up in eMERGE for physicians to follow and ensure that patients get any specialty care they need while admitted.

When super utilizers and high-risk patients are discharged from the hospital, they will leave with a follow-up appointment scheduled at a time that they have specifically said will be convenient for them. A pharmacist double checks each patient’s medications before they leave, and follows up with a phone call within two days to check in on the patient and make sure there are no medication issues. Additionally, all patients will receive improved discharge paperwork, which will have key information up front about red flags, who to call if there are issues, follow-up appointments, and medications.

The hospital is also working to ensure that patients continue to receive the services they may need post-discharge. This includes working with BMC primary and specialty care clinics and developing partnerships to leverage community resources such as Boston Healthcare for the Homeless to meet the complex psychosocial needs of patients and support improved transitions of care.

Super utilizers also receive additional attention. A super utilizer team, led by case manager Colby Bowden, RN, a pharmacy technician, and a social worker manage super utilizers during their admission and for 30 days post-hospitalization to support patients’ transitions out of the hospital. They meet patients at the bedside during their hospitalization, and then call each patient weekly to monitor clinical, medication, and psychosocial needs. If any issues arise, the team helps the patient get appropriate care, and serves a general liaison between the patient and needed services. If a patient in this program is not readmitted within 30 days, they “graduate” from the program and are reenrolled if they are admitted to the hospital at a later date.

In addition, the hospital is also targeting certain conditions that are associated with high readmission rates, such as sickle cell disease, substance use, or congestive heart failure. Patients with those conditions will also receive increased attention. Nurse practitioners will help manage patients with these clinical conditions across the care continuum, providing care during admission and seeing patients for follow up soon after discharge. This program is currently in place for patients with sickle cell disease and other programs will go live in the next few months.

“Preventing readmissions can be challenging because so many people touch patients before, during, and after their hospital stays,” says Yurkovic. “Everything we’re doing is a work in progress, but everyone involved is very excited by and engaged in this work. The hospital has a very collaborative environment, which makes a big difference for our work, and ultimately for our patients.”

Source: The BMC Brief 


Researchers Develop Tool to Predict Need for Life Support

By Rhiannon Iorio June 1st, 2016

Original Post:                                                          

It is now possible to determine which patients have an increased chance of one day needing life support with mechanical ventilation. Researchers have developed a simple tool to predict an individual’s five-year risk of requiring this care.

The study, which appears in Journal of the American Geriatric Society, may assist physicians in facilitating discussions around advanced care planning with patients and their families.

The need for mechanical ventilation during critical illness represents an event of significant short- and long-term consequence. Patients requiring mechanical ventilation have approximately 30 percent hospital mortality rates, a substantial risk of near-term death. Older patients who survive hospitalization requiring mechanical ventilation experience a doubling of pre-hospitalization disability levels, with approximately 60 percent requiring discharge to skilled care facilities, and 70 percent dying within 12 months. During this process patients often lose the ability to participate actively in shared decision making about what types of medical care they would like to receive.

The study used data from the Framingham Heart Study, focusing on participants age 65 years or older who were enrolled in Medicare. The researchers assigned points to factors that were found to be strongly associated with needing life support, including older age, male gender, diabetes, hypertension, atrial fibrillation, moderate to severe alcohol use, chronic pulmonary disease and hospitalization within the prior year. They then developed a scoring system to estimate the probability of needing life support within a five-year period. They validated the accuracy of their model by using the scoring system on clinical data collected from a similar demographic of patients from the Intermountain Healthcare system in Utah.

“We anticipate that a tool that improves the identification of people who are at risk for needing life support will allow for better communication between patients, family and physicians regarding patient wishes should these patients become incapacitated by critical illness,” explained corresponding author Allan Walkey, MD, MSc, assistant professor of medicine at Boston University School of Medicine. “Improved early communication may lead to later care more in-line with patient wishes, increasing patient autonomy and improving our ability to care for patients,” added Walkey who is also a pulmonary, allergy, sleep & critical care physician at Boston Medical Center.

The researchers hope this tool will assist physicians in correctly identifying individuals who are at high risk for requiring advanced life support, and allow meaningful discussions to occur that might allow patients and families to better prepare for a severe illness that requires support with a mechanical ventilator. They believe further study is needed to determine whether clinical implementation of a mechanical ventilation risk score would improve preparation for critical illness, including advance care planning.

Funding for this study was provided by the National Institutes of Health/National Heart, Lung, and Blood Institute (Walkey K01-HL116768, Benjamin 2R01HL092577), National Institutes of Health (Framingham Heart Study N01-HC25195), and National Institute of General Medical Sciences (Brown K23-GM094465).


Source: Boston University School of Medicine