An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental healthcare delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based upon a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental healthcare and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.

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Objective Recommended as a ‘universal precaution’ for improving provider–patient communication, teach-back has a limited evidence base. Discharge from the emergency department (ED) to home is an important high-risk transition of care with potential for miscommunication of critical information. We examined whether teach-back improves: comprehension and perceived comprehension of discharge instructions and satisfaction among patients with limited health literacy (LHL) in the ED. Methods We performed a randomized, controlled study among adult patients with LHL, to teach-back or standard discharge instructions. Patients completed an audio-recorded structured interview evaluating comprehension and perceived comprehension of (1) diagnosis, (2) ED course, (3) post-ED care, and (4) reasons to return and satisfaction using four Consumer Assessment of Healthcare Providers and Systems questions. Concordance with the medical record was rated using a five-level scale. We analyzed differences between groups using multivariable ordinal logistic regression. Results Patients randomized to receive teach-back had higher comprehension of post-ED care areas: post-ED medication (P < 0.02), self-care (P < 0.03), and follow-up instructions (P < 0.0001), but no change in patient satisfaction or perceived comprehension. Conclusion Teach-back appears to improve comprehension of post-ED care instructions but not satisfaction or perceived comprehension. Our data from a randomized, controlled study support the effectiveness of teach-back in a busy clinical setting. Further research is needed to test the utility and feasibility of teach-back for routine use including its impacts on distal outcomes.

Objectives To evaluate the diagnostic accuracy of five health literacy screening instruments in emergency department (ED) patients: the Rapid Evaluation of Adult Literacy in Medicine-Revised (REALM-R), the Newest Vital Sign (NVS), Single Item Literacy Screens (SILS), health numeracy, and physician gestalt. A secondary objective was to evaluate the feasibility of these instruments as measured by administration time, time on task, and interruptions during test administration. Methods This was a prospective observational cross-sectional study of a convenience sampling of adult patients presenting during March 2011 and February 2012 to one urban university-affiliated ED. Subjects were consenting non-critically ill, English-speaking patients over the age of 18 years without aphasia, dementia, mental retardation, or inability to communicate. The diagnostic test characteristics of the REALM-R, NVS, SILS, health numeracy, and physician gestalt were quantitatively assessed by using the short Test of Functional Health Literacy in Adults (S-TOHFLA). A score of 22 or less was the criterion standard for limited health literacy (LHL). Results Four hundred thirty-five participants were enrolled, with mean age of 45 years (SD ±15.7 years) and 18% had less than a high school education. As defined by an S-TOHFLA score of 22 or less, the prevalence of LHL was 23.9%. In contrast, the NVS, REALM-R, and physician gestalt identified 64.8%, 48.5%, and 35% of participants as LHL, respectively. A normal NVS screen was the most useful test to exclude LHL, with a negative likelihood ratio of 0.04 (95% CI = 0.01 to 0.17). When abnormal, none of the screening instruments, including physician gestalt, significantly increased the post-test probability of LHL. The NVS and REALM-R require 3 and 5 minutes less time to administer than the S-TOHFLA. Administration of the REALM-R is associated with less test interruptions. Conclusions One-quarter of these ED patients had marginal or inadequate health literacy. Among the brief screening instruments evaluated, a normal Newest Vital Sign result accurately reduced the probability of limited health literacy, although it will identify two-thirds of ED patients as high-risk for limited health literacy. None of the brief screening instruments significantly increases the probability of limited health literacy when abnormal.

A small proportion (1.9%) of emergency department patients undergoing CT of the neck, chest, abdomen, or pelvis have high cumulative rates of multiple or repeat imaging. Collectively, this patient subgroup may have a heightened risk of developing cancer from cumulative CT radiation exposure.

Objectives To determine whether patients with low health literacy have higher ED utilization and higher ED recidivism than patients with adequate health literacy. Methods The study was conducted at an urban academic ED with over 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (STOFHLA), and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period, and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis, and retaining those significant at an alpha of 0.05 in the final model. Results Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. Conclusions In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.