Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings

Abstract

Purpose Patient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions, but barriers persist for implementing them in routine care. Implementation science (IS) offers a potential way forward, but its application has been limited for PROMs/PREMs. Methods We compare similarities and differences for widely used IS frameworks and their applicability for implementing PROMs/PREMs through case studies. Three case studies implemented PROMs: (1) pain clinics in Canada; (2) oncology clinics in Australia; and (3) pediatric/adult clinics for chronic conditions in the Netherlands. The fourth case study is planning PREMs implementation in Canadian primary care clinics. We compare case studies on barriers, enablers, implementation strategies, and evaluation. Results Case studies used IS frameworks to systematize barriers, to develop implementation strategies for clinics, and to evaluate implementation effectiveness. Across case studies, consistent PROM/PREM implementation barriers were technology, uncertainty about how or why to use PROMs/PREMs, and competing demands from established clinical workflows. Enabling factors in clinics were context specific. Implementation support strategies changed during pre-implementation, implementation, and post-implementation stages. Evaluation approaches were inconsistent across case studies, and thus, we present example evaluation metrics specific to PROMs/PREMs. Conclusion Multilevel IS frameworks are necessary for PROM/PREM implementation given the complexity. In cross-study comparisons, barriers to PROM/PREM implementation were consistent across patient populations and care settings, but enablers were context specific, suggesting the need for tailored implementation strategies based on clinic resources. Theoretically guided studies are needed to clarify how, why, and in what circumstances IS principles lead to successful PROM/ PREM integration and sustainability.

Implementing person-centred outcome measures in palliative care: An exploratory qualitative study using Normalisation Process Theory to understand processes and context

“…Through demonstrating the value of Normalisation Process Theory as a robust theory for explaining the implementation of outcome measures in palliative care, this study also adds knowledge on implementation, acting on recent calls to 'advance our collective understanding of how, why, and in what circumstances [implementation science] frameworks and implementation strategies [may] produce successful implementation'. 16 Our data also presents novel contributions regarding the measure-specific challenges that healthcare professionals experience when using outcome measures, thus challenging a recent systematic review that argued 'challenges in implementing [outcome measures] are not exclusive to the characteristic of the chosen measure'. 1 Measure-specific challenges included confusion and ambiguity with regards to using Palliative Phase of Illness, and the art of communication required to effectively collect IPOS information.…”

“…15 Consequently, there has been calls for theoretical development in outcome measure implementation within palliative care. 8,10,[16][17][18] Implementation theories go beyond description by providing comprehensive and generalisable explanations of individual, organisational, and structural mechanisms underpinning implementation, including how, why and in which contexts specific relationships between barriers/ enablers might improve implementation effectiveness. 15 They offer an opportunity to 'move the field beyond simply identifying barriers and enablers of [outcome measure] implementation' by proactively specifying 'practical steps in translating research evidence into practice'.…”

“…15 They offer an opportunity to 'move the field beyond simply identifying barriers and enablers of [outcome measure] implementation' by proactively specifying 'practical steps in translating research evidence into practice'. 16 Whilst implementation theories have proved useful in implementing outcome measures in other fields, 16 they have not been used in palliative care outcomes research. In this study, our a priori awareness of implementation as a contextualised, dynamic process contingent on achieving alignment at multiple social levels, led us to select Normalisation Process Theory as the theoretical framework offering the greatest potential to provide insight into the implementation of outcome measures.…”

“…Implementation science – the systematic study of methods to promote the integration of evidence-based practices/interventions into routine practice 15 , 16 – presents a potential solution by providing a menu of theories and determinant frameworks to facilitate the implementation of outcome measures. 16 Determinant frameworks – such as the Consolidated Framework for Implementation Research and Promoting Action on Research Implementation in Health Services – have been used in palliative care research to describe the barriers/enablers to using outcome measures. 1 , 13 However, these frameworks are limited to description and categorisation rather than delivering the ‘explanatory power’ that is crucial in specifying the causal mechanisms that underpin implementation.…”

“… 15 Consequently, there has been calls for theoretical development in outcome measure implementation within palliative care. 8 , 10 , 16 – 18 …”