Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

Sarkies, Mitchell; Francis-Auton, Emilie; Long, Janet C.; Partington, Andrew; Pomare, Chiara; Nguyen, Hoa Mi; Wu, Wendy; Westbrook, Johanna I.; Day, Richard O.; Lévesque, Jean‐Frédéric; Mitchell, Rebecca; Rapport, Frances; Cutler, Henry; Tran, Yvonne; Clay‐Williams, Robyn; Watson, Diane E.; Arnolda, Gaston; Hibbert, Peter; Lystad, Reidar P.; Mumford, Virginia; Leipnik, George; Sutherland, Kim; Hardwick, Rebecca; Braithwaite, Jeffrey

doi:10.1136/bmjopen-2020-044049

Cited by 27 publications

(38 citation statements)

References 68 publications

(68 reference statements)

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“…This raises the meta-question, Have the benefits of an LHS been empirically demonstrated prior to implementation? LHS research is a radically applied field of inquiry that lends itself well to real-world evaluations, utilizing natural experiments in situ [ 81 , 82 ]. By leveraging study designs that evaluate the effectiveness of LHS-specific programs, systems, and platforms simultaneously with their implementation, there is an opportunity to accelerate the generation of empirical evidence for LHSs.…”

Section: Discussionmentioning

confidence: 99%

The Science of Learning Health Systems: Scoping Review of Empirical Research

et al. 2022

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Background The development and adoption of a learning health system (LHS) has been proposed as a means to address key challenges facing current and future health care systems. The first review of the LHS literature was conducted 5 years ago, identifying only a small number of published papers that had empirically examined the implementation or testing of an LHS. It is timely to look more closely at the published empirical research and to ask the question, Where are we now? 5 years on from that early LHS review. Objective This study performed a scoping review of empirical research within the LHS domain. Taking an “implementation science” lens, the review aims to map out the empirical research that has been conducted to date, identify limitations, and identify future directions for the field. Methods Two academic databases (PubMed and Scopus) were searched using the terms “learning health* system*” for papers published between January 1, 2016, to January 31, 2021, that had an explicit empirical focus on LHSs. Study information was extracted relevant to the review objective, including each study’s publication details; primary concern or focus; context; design; data type; implementation framework, model, or theory used; and implementation determinants or outcomes examined. Results A total of 76 studies were included in this review. Over two-thirds of the studies were concerned with implementing a particular program, system, or platform (53/76, 69.7%) designed to contribute to achieving an LHS. Most of these studies focused on a particular clinical context or patient population (37/53, 69.8%), with far fewer studies focusing on whole hospital systems (4/53, 7.5%) or on other broad health care systems encompassing multiple facilities (12/53, 22.6%). Over two-thirds of the program-specific studies utilized quantitative methods (37/53, 69.8%), with a smaller number utilizing qualitative methods (10/53, 18.9%) or mixed-methods designs (6/53, 11.3%). The remaining 23 studies were classified into 1 of 3 key areas: ethics, policies, and governance (10/76, 13.2%); stakeholder perspectives of LHSs (5/76, 6.6%); or LHS-specific research strategies and tools (8/76, 10.5%). Overall, relatively few studies were identified that incorporated an implementation science framework. Conclusions Although there has been considerable growth in empirical applications of LHSs within the past 5 years, paralleling the recent emergence of LHS-specific research strategies and tools, there are few high-quality studies. Comprehensive reporting of implementation and evaluation efforts is an important step to moving the LHS field forward. In particular, the routine use of implementation determinant and outcome frameworks will improve the assessment and reporting of barriers, enablers, and implementation outcomes in this field and will enable comparison and identification of trends across studies.

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Section: Discussionmentioning

confidence: 99%

The Science of Learning Health Systems: Scoping Review of Empirical Research

et al. 2022

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“…It is now acknowledged that while the early linear models of knowledge translation delivered substantial advances in medicine (e.g. vaccines for communicable disease, antibiotics and antivirals, and cholesterol lowering pharmaceuticals), they are limited in application to complex healthcare interventions, such as educational programs, environmental improvements, or health promotion initiatives, that require multiple interdependent or interacting components (Campbell et al, 2000;Sarkies et al, 2020b). In health care organisations, implementation is generally understood as a multilevel, multifactorial, multidimensional activity (Aarons et al, 2014;Sarkies et al, 2020a).…”

Section: Implementation Science In Health Care Organisationsmentioning

confidence: 99%

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Sarkies

Robinson

Ludwick

et al. 2021

JHOM

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PurposeAs a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.Design/methodology/approachThe authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.FindingsWithin the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.Originality/valueThis paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

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“…Accessing and applying research evidence to guide resource allocation decisions can be difficult for healthcare managers [18,19]. Therefore, it is imperative to evaluate strategies that promote evidence-informed decision-making to ensure that the benefits of research on weekend allied health service models can be translated to improved health outcomes.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

et al. 2021

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Background Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services. Methods and findings This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI −8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI −6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β −9.12 [95% CI −3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β −0.12 [95% CI −0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β −0.19 [−1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI −1.36 to 5.74] p = 0.219; knowledge broker versus control β −0.55 [95% CI −1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β −3.75 [95% CI −8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination. Conclusions Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

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Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

Cited by 27 publications

References 68 publications

The Science of Learning Health Systems: Scoping Review of Empirical Research

The Science of Learning Health Systems: Scoping Review of Empirical Research

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

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