背景:尽管数十年的证据表明高血压护理在降低发病率和死亡率方面的功效,大多数高血压病例仍然不受控制。迫切需要阐明和解决临床工作人员在提供循证高血压护理时面临的多层次促进者和障碍,患者面对它,和临床系统在维持它方面面临的问题。通过严格的实施前评估,我们的目的是在纽约市一家拥有联邦资格的大型健康中心(FQHC)的6个初级保健中心,确定可能影响计划实施的多层次技术辅助高血压管理试验的促进者和障碍.
方法:在专门的实施前期间(3-9个月/站点,2021-2022),由训练有素的实践促进者进行了能力评估,包括(1)在线匿名调查(n=124;符合条件的70.5%),(2)高血压训练分析(n=69;94.5%的分配),(3)与FQHC领导和工作人员进行音频录制的半结构化访谈(n=67;符合条件的48.6%)。调查测量了员工的社会人口统计学特征,适应性储备,基于证据的实践态度,通过验证的量表和实施领导得分。培训分析,来自课程结束的测验,包括平均得分和通过所需的次数。访谈评估了工作人员报告的促进者和当前高血压护理交付和吸收的障碍;音频转录后,训练有素的定性研究人员采用了演绎编码方法,由实施研究综合框架(CFIR)提供信息。
结果:大多数调查受访者报告了适度的适应性准备金(平均值=0.7,范围=0-1),循证实践态度(平均值=2.7,范围=0-4),和实施领导(平均值=2.5,范围=0-4)。大多数员工第一次尝试就通过了培训课程,并表现出高分(平均>80%)。访谈的结果确定了潜在的促进者和实施障碍;具体来说,工作人员报告说,高血压护理的复杂障碍,control,和临床沟通存在;有一个公认的需要改善高血压护理;在临床挑战与数字工具访问强加的工作流程延迟;尽管高病人负荷,员工有动力提供高质量的护理。
结论:本研究是首次在FQHC的研究背景下将CFIR应用于严格的实施前评估的研究之一,并且可以作为寻求识别和解决已知影响实施成功的环境因素的类似试验的模型。
背景:ClinicalTrials.govNCT03713515,注册日期:2018年10月19日。
BACKGROUND: Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City.
METHODS: During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR).
RESULTS: Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares.
CONCLUSIONS: This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success.
BACKGROUND: ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.