implementation of the better 2 program

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Implementation of the BETTER 2 program

Nicolette Sopcak, Carolina Aguilar, Kris Aubrey-Bassler, Richard Cullen, Melanie Heatherington, Donna Manca

CPHA Conference TorontoMay 28, 2014

A qualitative evaluation

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www.better.utoronto.ca

Acknowledgements & Disclaimer

Production of this presentation has been made possible through a financial contribution from Health Canada, through the Canadian Partnership Against

Cancer.

The views expressed herein represent the views of the BETTER 2 Coalition and do not necessarily represent the views of the project funders.

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Outline

• Background & Rationale• The BETTER approach• BETTER 2 - qualitative•Methods• Findings• Conclusion• Questions

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What is BETTER?• BETTER stands for Building on Existing Tools to

Improve Chronic Disease Prevention and Screening in Primary Care

• The aim of BETTER is to improve chronic disease prevention and screening (CDPS) for chronic diseases such as• Diabetes• Heart disease• Cancer (colon, breast, cervical)• and associated lifestyles (e.g., physical activity, diet,

alcohol)

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Why Chronic Disease Prevention and Screening (CDPS)?

• Background & Rationale• The BETTER approach• BETTER 2• Implementation•Methods• Findings• Conclusion• Questions

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Issues• Chronic diseases are steadily increasing• Primary care is the ideal setting for CDPS• --> but• Physicians lack the time for comprehensive CDPS• Physicians have other demands (acute care,

managing CD)• Inconsistent application of tools & strategies (some

guidelines lack rigour or are inconsistent across provinces and territories)

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Context BETTER 1• 8 Primary Care Teams (PCT)• 2 Interventions:• Patient level intervention: Prevention Practitioner (PP)

(prevention visits with patients, develop prevention prescription through shared decision making)

• Practice level intervention: Practice Facilitator(enable EMR (invitation letters, audit and feedback, decision support, prepare a “prevention prescription” tailored to the circumstances of each PCT)

• Patient level (PP) intervention was the most effective BETTER 2 expansion (different settings in NL and NWT)

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The Prevention Practitioner Role1) Invite patients (age 40-65)

2) First health check (medical history, identify eligible maneuvers)

3) Prevention visit with PP using shsshared shared decision making

- personalized prevention prescription- links to other resources (e.g., dietician,

physician, smoking cessation)

4) Re-assess & check-in with patients at follow-up (e.g., 3, 6, 12 months)

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BETTER 2 - qualitative• Implementation in different settings (urban, rural,

and remote in NL)

• 4 guiding questions: • Impact of having a PP on the health setting in each

community?• What adaptations may be needed?• Barriers and enablers? • How can BETTER 2 be improved?

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Methods• Qualitative program evaluation

• 2 Focus Groups & 10 key informant interviews health care providers (physicians, PPs, others), administrators, managers, researchers

• Iterative process using constant comparison for data analysis

• Employing the Consolidated Framework for Implementation Research (CFIR) by Damschroder et al., 2009)1

1systematic & comprehensive framework based on extensive review (synthesizes 19 existing frameworks, allows comparison with other implementation)

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CFIR (5 domains)1) Intervention characteristic (e.g., adaptability,

complexity, cost)

2) Outer setting (e.g., patient needs, resources, external policies and incentives)

3) Inner setting (e.g., team networks, communication, culture, climate)

4) Characteristics of individuals (e.g., knowledge, ability, motivation)

5) Process (e.g., planning, engaging, reflecting & evaluating)

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CFIR (5 domains)by Damschroder, Aron, Keith, Kirsh, Alexander, & Lowery (2009)

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Preliminary Findings1) Intervention characteristic: Evidence strength & quality• Strong evidence from BETTER trial, • Perceived cost (major barrier) – physician cost perception, • Complexity – comprehensive program, requires time

2) Outer setting: External policies and incentives • Physicians’ billing (salary vs. fee for service), lack of teams

in primary care, lack of time, health consultations can often not be delegated, support from health authorities

3) Inner setting: Networks and communication, culture• Team vs. single physician, relationships in team, • Implementation climate (e.g., competition, relationships)

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Preliminary Findings4) Characteristics of Individuals: Knowledge and belief about

the intervention • Steep initial learning curve requires time commitment, with

expertise PP visits become more efficient, • Other personal attributes (e.g. skills, values, motivation to

do PP visits, compatibility of PP role with other roles)5) Process: Planning, Engaging • Start conversations early - inviting input before

implementation, engaging right individuals, frequent check-ins, • Executing (e.g. adapting strategies, tracking progress),• Reflecting and evaluating (e.g. sharing learned lessons)

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Conclusion (our main learnings) BETTER 2 impact

PPs like it, patients are motivated & like to know where they stand, community resources/connections

Physicians are more skeptical than PPs, clinic staff, and administrators re: cost (billing), sharing responsibilities, & competencies

Important enablers/barriers Team culture, relationships (e.g., working in a team and as

a team, trust, communication, shared responsibilities) Support from health authorities, government Awareness and knowledge about BETTER

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Conclusion (our main learnings) PP role

Background (LPN, NP), Personal motivation, Steep learning curve requires initiative & commitment

Process (implementation) Starting conversations early, inviting input, frequent

check-ins and positive relationships and good tracking are key,

Plan carefully: who to invite, and how to share CDPS responsibilities most effectively

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Thank you!

Do you have any questions or comments?

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ReferencesDamschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. doi:10.1186/1748-5908-4-50

Ritchie, J. & Spencer, L. (2002). Qualitative data analysis for applied policy research. In The Qualitative Researcher’s Companion by A. M. Huberman & M. B. Miles (Eds.), pp. 305-329.

Picture of Prevention Practitioner (PP) from www.visualphotos.com

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BETTER Publications• BETTER Trial results• Grunfeld, E., Manca, D., Moineddin, R., Thorpe, K.E., Hoch, J.S.,

Campbell-Scherer, D., Meaney, C., Rogers, J., Beca, J., Krueger, P., Mamdani, M. Improving Chronic Disease Prevention and Screening in Primary Care: Results of the BETTER Pragmatic Cluster Randomized Controlled Trial. BMC Family Practice 2013: 14 (175). Available online: http://www.biomedcentral.com/1471-2296/14/175.

• BETTER Trial qualitative evaluation• Grunfeld, E., Manca, D., Moineddin, R., Thorpe, K.E., Hoch, J.S.,

Campbell-Scherer, D., Meaney, C., Rogers, J., Beca, J., Krueger, P., Mamdani, M. Improving Chronic Disease Prevention and Screening in Primary Care: Results of the BETTER Pragmatic Cluster Randomized Controlled Trial. BMC Family Practice 2013: 14 (175). Available online: http://www.biomedcentral.com/1471-2296/14/175.

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BETTER trial publication

• Background & Rationale• The BETTER approach• BETTER 2• Implementation•Methods• Findings• Conclusion

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Algorithm

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Bubble diagram

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Primary Outcome• SQUID Analysis• The SQUID (Summary QUality InDex) determined the proportion

of maneuvers or items for which a participant was eligible (E) at baseline that had been met (M) at follow-up

• A SQUID score is simply a ratio for each patient

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Summary of Results Across GroupsControl PF only PP only PP & PF

Mean Follow-up time (days) 212 214 230 235

Mean Number of Es (SD) 9.07 (3.38) 8.54 (3.15) 8.93 (3.15) 9.18 (3.13)

Mean Number of Ms (SD) 1.91 (1.76) 2.61 (2.30) 4.71 (2.65) 5.28 (2.64)

Mean SQUID (SD) 0.21 (0.17) 0.28 (0.24) 0.54 (0.26) 0.58 (0.24)

• Balanced Mean follow-up time• Balanced distribution of Eligibility• Patients receiving the PP intervention accomplish more items

and scored a higher Summary Quality Index (compared to groups not receiving the PP intervention)

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Summary Across StrataControl PF only PP only PP & PF

Mean Follow-up time (days) 210 211 227 245



Mean SQUID (SD) 0.20 (0.19) 0.24 (0.22) 0.47 (0.26) 0.56 (0.25)

Mental Health

Control PF only PP only PP & PFMean Follow-up time (days) 214 215 231 229



Mean SQUID (SD) 0.21 (0.17) 0.30 (0.24) 0.58 (0.30) 0.60 (0.23)

Non-Mental Health

• Mental health patients:• Have a greater amount of baseline eligibility than non-mental health patients• Achieved fewer positive outcomes than non-mental health patients• Scored lower on the SQUID• Effect of the PP group is still significant

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BETTER 2 Logic model

implementation of the better 2 program

Documents

better stands

aim of better

chronic disease prevention

screening cdps

increasingprimary care

chronic diseases

health setting

health canada