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12-lead ECG from a man with a history of atrial fibrillation and dilated cardiomyopathy, age 43 years, with palpitations and shortness of breath. Demonstrates a wide-complex, regular tachycardia with a ventricular rate of 200 beats/minute, consistent with probable monomorphic ventricular tachycardia.
Source publication
Introduction:
Since 2003, Kaiser Permanente (KP) has implemented innovative cardiovascular disease (CVD) risk-reduction clinical practices in Northern and Southern California that emphasize the use of cardioprotective medications-aspirin, angiotensin-converting enzyme inhibitors, and statins-in individuals at very high risk of experiencing heart a...
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Background:
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Citations
... Till date, these strategies have predominantly been studied in healthcare settings [1,[4][5][6]. Many implementation studies and outcomes are related to clinical healthcare or leveraging com-munity-based systems to sustain clinical or behavioral interventions [7][8][9][10]. Just as healthcare providers are challenged with integrating EBIs in clinical settings, public health professionals are challenged with integrating EBIs in community settings [11][12][13][14][15]. ...
In this commentary, we introduce public health practitioners and researchers to implementation science through an established compilation of implementation strategies. We provide terminology and examples for community settings so public health practitioners and researchers can use implementation strategies and document efforts using standard terminology. We also discuss the need for future work to determine the extent to which these implementation strategies work and are most useful in community settings, and ultimately, how health behaviors are impacted. We intend this commentary to serve as a dissemination strategy for implementation strategies and to contribute to knowledge in the growing field of implementation science in community settings.
... 20 The integrated health system then shared the programs with community health centers and public hospitals beginning in 2007. 21,22 This community implementation included grant funding and technical consultative support. From 2007 to 2016, the program expanded to include a formal learning community and a structured quality improvement component. ...
Those with diabetes are at an increased risk of cardiovascular disease (CVD). Safety net clinics serve populations that bear a significant burden of disease and disparities and are a key setting in which to focus on reducing CVD. An integrated health system provided funding and technical assistance (TA) to safety net organizations (community health centers and public hospitals) in Northern California to decrease the risk of cardiovascular events for patients with diabetes. This was a program called Preventing Heart Attacks and Strokes Everyday (PHASE), which combined an evidence-based medication protocol with population health management and team-based care strategies. The TA supported organizations by sharing best practices, providing quality improvement coaching, and facilitating peer learning. A mixed-methods evaluation found that organizations involved in PHASE improved rates of blood pressure control and cardioprotective medication prescriptions for patients with diabetes. They made progress on these measures through strategies such as leveraging team-based care, providing education on evidence-based protocols, and using data to drive improvements. The evaluation concluded that financially supporting and providing focused TA to safety net organizations can help them build capacity and leverage their strengths to improve outcomes and potentially decrease the risk of heart attacks and strokes in communities.
... Prior efforts to translate the Kaiser intervention bundle to CHCs were successful, but less so than the trial by Kaiser Permanente of Northern California that first established its effectiveness. 16 This suggests there is a need for a focused effort to implement the bundle in a way that is both acceptable to community members and feasible to implement. ...
To reduce mortality for people experiencing cardiovascular health disparities, new innovations in health care must be implemented with strategic partnerships that involve trusted organizations and community members.
... The ALL initiative was implemented at Kaiser Permanente (KP) on the basis of compelling evidence for these medicines' effectiveness. [10][11][12] Adult KP patients who took the ALL medications had notable reduced risks of cardiovascular disease hospitalization; overall rates of myocardial infarctions also declined substantially. 13 The strong underlying evidence, and considerable impact of the ALL initiative in KP, indicated the potential benefits of attempting to implement the ALL initiative in CHCs. Intervention components of KP were electronic health recordebased tools designed to streamline identification of patients missing indicated medications and prescribing the medications ( Table 2). ...
Unlabelled:
The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention's components. Such strategies have not been regularly reported in descriptions of interventions' effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into "real-world" practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings.
Trial registration:
clinicaltrials.gov Identifier: NCT02299791.
... Kaiser Permanente (KP), a large integrated health care delivery system, developed the "A.L.L. Initiative" (aspirin, lovastatin (any statin), lisinopril (any angiotensinconverting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)), hereafter called "ALL"). ALL is a system-level QI intervention designed to increase the percentage of patients with cardiovascular disease (CVD)/diabetes mellitus (DM) taking cardioprotective medications according to national treatment guidelines [50]. At KP, the ALL intervention uses electronic health record (EHR) reminders and panel management tools to help providers identify patients indicated for but not taking an ALL medication. ...
... The ALL implementation strategies used at KP involve incentivizing providers to appropriately prescribe the ALL medications (via pay bonuses related to overall care quality) and directives identifying it as KP's standard of care. At KP, ALL led to an estimated > 60 % reduction in CVD events among targeted adults [50]. ...
Background:
Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting.
Methods/design:
This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices.
Discussion:
Having a better understanding of how different strategies support implementation efforts could positively impact the field of implementation science, by comparing practical, generalizable methods for implementing clinical innovations in community health centers. Bridging this gap in the literature is a critical step towards the national long-term goal of effectively disseminating and implementing effective interventions into community health centers.
Trial registration:
ClinicalTrials.gov, NCT02325531.
... ALL was highly successful in KP: an internal study estimated a >60 % reduction in cardiovascular disease (CVD) events among targeted adults taking the ALL medications for 1-2 years [4,5]. We selected ALL as a "test case" for studying cross-setting translational implementation based on its strong underlying evidence [4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], its alignment with national treatment guidelines, its impressive impact at KP, the simplicity of its strategies, and preliminary evidence that it could be adapted for the safety net [6]. ...
... ALL was highly successful in KP: an internal study estimated a >60 % reduction in cardiovascular disease (CVD) events among targeted adults taking the ALL medications for 1-2 years [4,5]. We selected ALL as a "test case" for studying cross-setting translational implementation based on its strong underlying evidence [4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], its alignment with national treatment guidelines, its impressive impact at KP, the simplicity of its strategies, and preliminary evidence that it could be adapted for the safety net [6]. ...
Integrated health care delivery systems devote considerable resources to developing quality improvement (QI) interventions. Clinics serving vulnerable populations rarely have the resources for such development but might benefit greatly from implementing approaches shown to be effective in other settings. Little trial-based research has assessed the feasibility and impact of such cross-setting translation and implementation in community health centers (CHCs). We hypothesized that it would be feasible to implement successful QI interventions from integrated care settings in CHCs and would positively impact the CHCs.
We adapted Kaiser Permanente's successful intervention, which targets guideline-based cardioprotective prescribing for patients with diabetes mellitus (DM), through an iterative, stakeholder-driven process. We then conducted a cluster-randomized pragmatic trial in 11 CHCs in a staggered process with six "early" CHCs implementing the intervention one year before five "'late" CHCs. We measured monthly rates of patients with DM currently prescribed angiotensin converting enzyme (ACE)-inhibitors/statins, if clinically indicated. Through segmented regression analysis, we evaluated the intervention's effects in June 2011-May 2013. Participants included ~6500 adult CHC patients with DM who were indicated for statins/ACE-inhibitors per national guidelines.
Implementation of the intervention in the CHCs was feasible, with setting-specific adaptations. One year post-implementation, in the early clinics, there were estimated relative increases in guideline-concordant prescribing of 37.6 % (95 % confidence interval (CI); 29.0-46.2 %) among patients indicated for both ACE-inhibitors and statins and 38.7 % (95 % CI; 23.2-54.2 %) among patients indicated for statins. No such increases were seen in the late (control) clinics in that period.
To our knowledge, this was the first clinical trial testing the translation and implementation of a successful QI initiative from a private, integrated care setting into CHCs. This proved feasible and had significant impact but required considerable adaptation and implementation support. These results suggest the feasibility of adapting diverse strategies developed in integrated care settings for implementation in under-resourced clinics, with important implications for efficiently improving care quality in such settings. CLINICALTRIALS.GOV: NCT02299791 .
... Colorectal cancer (CRC) is the second-leading cause of cancer deaths [1]. In 2013, an estimated 142,000 adults in the U.S. will be diagnosed with CRC and 51,000 will die from the disease [2,3]. Accelerating adoption of screening could reduce CRC mortality more than 50% by 2020 [4]. ...
The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) study is collaboration among two research institutions and health-systems partners. The main study, scheduled to begin in 2014, will assess effectiveness of an intervention program using electronic health record (EHR) clinical decision support (CDS) tools to improve rates of colorectal-cancer screening in federally qualified health centers (FQHCs). Very few studies, and no large studies, aimed at raising CRC screening rates have utilized an EHR-embedded system.
We piloted the use of an EHR-embedded real-time patient registry reporting tool in a pilot study undertaken prior to beginning our main CRC screening study. The pilot study goal was to assess feasibility and effectiveness of two clinic-based approaches to raising rates of colorectal cancer screening among selected patients aged 50-74 who were not up-to-date with colorectal-cancer screening guidelines. We used work sessions and qualitative interviews with clinic personnel to assess performance of the tool, as well as to identify specific elements of the tool's functionality needing refinement.
Two critical elements of the EHR tool allowed us to mail FIT kits efficiently to appropriate patients: (1) having a direct interface with the laboratory that processed the FITs, thus allowing for real-time updates to the registry; and (2) being able to place lab orders from a list of selected patients. We identified the following elements that needed refining: the use of Health Maintenance (EHR function for tracking screening eligibility and due dates incorporating STOP CRC inclusion and exclusion criteria), and the development of report templates for identifying patients eligible for each step.
We found that most elements of our EHR-embedded program worked well and that specific refinement may improve the accuracy of identifying patients at each step. Our findings can inform future efforts to build EHR-embedded CDS tools for preventive services.
... As implemented at KP nationally starting in 2003, the initiative includes electronic reminders for care providers, tailored panel management tools, and targeted outreach to patients. 14,15 At Kaiser Permanente North-west, the EHRbased functions supporting the A.L.L. Initiative are integrated into KP's Panel Support Tool, which includes two main functions: point-of-care summaries of patient data, with highlighted 'care gaps' and suggested actions, and a 'panel view' panel management tool that supports targeted outreach and flexible reporting. 1,2 For images of these tools and more information, see Zhou et al. 2011 1 and Feldstein et al. 2010. 2 An internal review estimated that implementation of the initiative was associated with a greater than 60% reduction in heart attacks and strokes among KP patients with diabetes; another study showed a 24% reduction in myocardial infarctions, and a 62% reduction in the relative incidence of serious infarctions, among 46,000 KP members. ...
... 1,2 For images of these tools and more information, see Zhou et al. 2011 1 and Feldstein et al. 2010. 2 An internal review estimated that implementation of the initiative was associated with a greater than 60% reduction in heart attacks and strokes among KP patients with diabetes; another study showed a 24% reduction in myocardial infarctions, and a 62% reduction in the relative incidence of serious infarctions, among 46,000 KP members. [14][15][16] As a result of these achievements, the A.L.L. Initiative won the prestigious national James A. Vohs award for care quality. 15 ...
This case study describes how we are translating a diabetes care quality improvement initiative from an insured (HMO) setting into federally qualified health centers (FQHCs). We outline the innovative collaborative processes whereby researchers and FQHC providers adapted this initiative, which includes health information technology tools, to meet the FQHCs' needs.
Objectives
Hypertension affects 1 in 3 adults in the United States and disproportionately affects African Americans. Kaiser Permanente demonstrated that a “bundle” of evidence-based interventions significantly increased blood pressure control rates. This paper describes a multiyear process of developing the protocol for a trial of the Kaiser bundle for implementation in under-resourced urban communities experiencing cardiovascular health disparities during the planning phase of this biphasic award (UG3/UH3).
Methods
The protocol was developed by a collaboration of faith-based community members, representatives from community health center practice-based research networks, and academic scientists with expertise in health disparities, implementation science, community-engaged research, social care interventions, and health informatics. Scientists from the National Institutes of Health and the other grantees of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Alliance also contributed to developing our protocol.
Results
The protocol is a hybrid type 3 effectiveness-implementation study using a parallel cluster randomized trial to test the impact of practice facilitation on implementation of the Kaiser bundle in community health centers compared with implementation without facilitation. A central strategy to the Kaiser bundle is to coordinate implementation via faith-based and other community organizations for recruitment and navigation of resources for health-related social risks.
Conclusions
The proposed research has the potential to improve identification, diagnosis, and control of blood pressure among under-resourced communities by connecting community entities and healthcare organizations in new ways. Faith-based organizations are a trusted voice in African American communities that could be instrumental for eliminating disparities.
Importance:
Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes.
Objective:
To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs).
Design, setting, and participants:
This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention.
Interventions:
A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations.
Main outcomes and measures:
One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control).
Results:
Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001).
Conclusions and relevance:
The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk.
Trial registration:
ClinicalTrials.gov Identifier: NCT03001713.
