The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample

Abstract

BackgroundHepatitis C virus (HCV) is a common and highly morbid illness. New medications that have much higher cure rates have become the new evidence-based practice in the field. Understanding the implementation of these new medications nationally provides an opportunity to advance the understanding of the role of implementation strategies in clinical outcomes on a large scale. The Expert Recommendations for Implementing Change (ERIC) study defined discrete implementation strategies and clustered these strategies into groups. The present evaluation assessed the use of these strategies and clusters in the context of HCV treatment across the US Department of Veterans Affairs (VA), Veterans Health Administration, the largest provider of HCV care nationally.MethodsA 73-item survey was developed and sent to all VA sites treating HCV via electronic survey, to assess whether or not a site used each ERIC-defined implementation strategy related to employing the new HCV medication in 2014. VA national data regarding the number of Veterans starting on the new HCV medications at each site were collected. The associations between treatment starts and number and type of implementation strategies were assessed.ResultsA total of 80 (62%) sites responded. Respondents endorsed an average of 25 ± 14 strategies. The number of treatment starts was positively correlated with the total number of strategies endorsed (r = 0.43, p < 0.001). Quartile of treatment starts was significantly associated with the number of strategies endorsed (p < 0.01), with the top quartile endorsing a median of 33 strategies, compared to 15 strategies in the lowest quartile. There were significant differences in the types of strategies endorsed by sites in the highest and lowest quartiles of treatment starts. Four of the 10 top strategies for sites in the top quartile had significant correlations with treatment starts compared to only 1 of the 10 top strategies in the bottom quartile sites. Overall, only 3 of the top 15 most frequently used strategies were associated with treatment.ConclusionsThese results suggest that sites that used a greater number of implementation strategies were able to deliver more evidence-based treatment in HCV. The current assessment also demonstrates the feasibility of electronic self-reporting to evaluate ERIC strategies on a large scale. These results provide initial evidence for the clinical relevance of the ERIC strategies in a real-world implementation setting on a large scale. This is an initial step in identifying which strategies are associated with the uptake of evidence-based practices in nationwide healthcare systems.

Tracking Implementation Strategies in the Randomized Rollout of a Veterans Affairs National Opioid Risk Management Initiative

“…Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR: 16-31) strategies. The median case review completion rate was 71% (IQR: 48%-95%).…”

“…In both implementation efforts, early success was associated with training/education and tailoring to the context. 15,16 We also found that tailoring the survey for the STORM implementation effort allowed us to reduce the number of strategies that we assessed. The information that was learned from these assessments of stakeholder-reported implementation strategies in vastly different implementation efforts speaks to the value of this approach to assessing implementation strategies.…”

“…However, we have previously found high interrater reliability between multiple respondents from the same facility in a similar study using a similar survey. 16 Finally, we conducted multiple statistical tests using a relatively small number of facilities, which allows us to generate hypotheses but not draw definitive conclusions from the findings. Despite these limitations, this was a national, randomized program evaluation with excellent response rates, and our findings add to a growing body of literature assessing a wide variety of implementation strategies across large-scale implementation efforts.…”

“…The Expert Recommendations for Implementing Change (ERIC) group recently specified, defined, and clustered 73 implementation strategies, 12−14 We previously developed a tool to assess ERIC-defined implementation strategies in the context of VA's national effort to expand the use of newer, more effective hepatitis C (HCV) medications. 15,16 In these prior efforts, we found that the number of strategies used was associated with more treatment starts and that specific strategies were associated with improved uptake of the newer evidence-based medications. However, it was unclear whether this survey could work to understand other implementation efforts.…”

“…The original 73 ERIC implementation strategies were reviewed by the evaluation team with the goal of adapting our prior implementation strategy survey to this particular evaluation. 15,16 After review, four financial strategies were deemed irrelevant in VA and omitted from the survey ("capitated payments"; "change liability laws"; "place innovation on fee for service lists/ formularies"; and "alter patient/consumer fees"). Furthermore, "develop and organize quality monitoring systems" was omitted because it was inherent to the STORM dashboard.…”