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implementation for chronic diseases (TICD):
A project protocol

Michel Wensing, Andy Oxman, Richard Baker, Maciek Godycki-Cwirko, Signe Flottorp, Joachim Szecsenyi, Jeremy Grimshaw and Martin Eccles

Tailored implementation interventions are strategies that are designed to achieve desired changes in healthcare practice based on an assessment of determinants of healthcare practice. Systematic tailoring entails three key steps: identification of the determinants of healthcare practice, designing implementation interventions appropriate to the determinants, and application and assessment of implementation interventions that are tai-lored to the identified determinants. While the process of 'tailoring' may be used refer to the second step only, in this paper it is used in a more comprehensive way to include these three steps. 'Tailored implementation interventions' is the short phrase for implementation interventions resulting from a tailoring process. Little research evidence is available regarding how tailoring is best done in relation to implementation interventions.

Determinants of healthcare practice are factors that might prevent or enable improvements. Such factors are sometimes referred to as barriers and enablers, barriers and facilitators, problems and incentives, or as moderators and mediators. These include factors that can be modified (e.g., knowledge of health professionals) and non-modifiable factors that can be used to target  inter-ventions (e.g., wider organizational structures). Determi-nants of current practice are included if they are relevant to achieving change. The factors can be related to professional behaviour, organisation of healthcare, and health system arrangements. They can also be related to patient behaviours that might prevent or enable healthcare improvements and characteristics of the social and political environment, which might constrain or enable efforts to improve health services. Factors may be pragmatically defined or linked to theoretical perspectives. Healthcare improvements include improvements in any healthcare setting (including pri-mary and secondary care) and improvements in public health services as well as clinical services.

The assumption underlying tailoring is that implemen-tation interventions are most helpful if these effectively address the most important determinants of practice for improvement in the targeted setting. This is consistent with a rational approach to clinical practice, where a diagnosis is made in order to guide the choice of treatment. The idea is also shared with a large number of theories and models for inducing behavioural and organizational change, which have been developed in various scientific disciplines such as motivational psychology, organisational science, and educational research. Many descriptive studies of determinants of practice have been published in medical journals and an increasing number of implementation interventions have been labeled 'tailored implementation interventions.' Although tailoring implementation interventions to determinants of practice seems logical and has received growing attention, research evidence that tailored strategies are substantially more effective than other approaches is lacking.

Furthermore, it is unclear how best to identify important determinants of practice and how to match imple-mentation interventions to those. A range of approaches is available for the different steps in tailoring, as will be outlined in the following section. It is unclear which ones are most appropriate. For example, a meta-regres- sion analysis on 26 studies of tailored interventions did not identify impact of level of tailoring, rigour of barrier analysis, complexity of interventions, concealment of allocation, explicit utilisation of a theory when developing the intervention, and the repoted presence or absence of administrative  constraints. The Tailored Implementation For Chronic Diseases (TICD) project aims to address this lack of research evidence by directly comparing alternative approaches in the tailoring process and by assessing the effectiveness of resulting tailored implementation interventions.

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A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice

Signe A Flottorp, Andrew D Oxman, Jane Krause, Nyokabi R Musila, Michel Wensing, Maciek Godycki-Cwirko, Richard Baker and Martin P Eccles    

Tailored implementation interventions are strategies that are designed to achieve improvements in healthcare based on an assessment of determinants of practice. There is systematic review evidence that tailored interventions can improve healthcare, although the review identified that there was a clear need for an improved understanding of the methods of tailoring. Systematic tailoring entails (at least) three key steps: identification of the determinants of practice, designing implementation interventions appropriate to the determinants, and application and assessment of implementation interventions that are matched to the identified determinants.

The basic idea underlying tailored interventions is that different types and constellations of influences or determinants affect different types of practice changes. To implement an evidence-based recommendation in a specific context, we may need detailed information about how specific determinants might affect the desired changes in practice. The changes needed to implement different recommendations vary widely; some changes are relatively simple, while other changes are more complex; e.g., requiring new ways of delivering or organising care. Different determinants are likely to affect different types of changes. The impact of a specific determinant for a specific type of change may vary across different contexts and different health professionals within a given context.

Determinants of healthcare professional practice are factors that might prevent or enable improvements in that practice. Such factors have also been referred to as barriers and enablers, barriers and facilitators, problems and needs, or disincentives and incentives. Determinants of practice may act as moderators or ‘effect modifiers,’ or they may act as mediators; indicating that they are links in a chain of causal mechanism. We have limited evidence on the moderating or mediating influence of specific determinants on the effectiveness of implementation interventions. It is unlikely that there is a simple linear causal relationship linking specific determinants to specific changes in practice; rather, it is more plausible that different determinants interact in ways that make it difficult to confidently predict the likely impact of each specific determinant.

Several checklists, frameworks, taxonomies, and classifications of determinants of practice have been published. Some of these have been developed based on theories, and some based on empirical  research.

Stavri and Michie have identified six different types of classification systems from the natural, medical, and social sciences: nomenclatures, hierarchical classification, matrix classification, ordered sets, faceted classification, and social categorization systems. Different terms such as checklist, framework, taxonomy, and classifications may represent different ways of framing, understanding, or thinking about the idea of determinants of practice. However, for applied purposes they can also be considered to be similar tools. We use the term ‘checklist’ as a generic term for any system for identifying and classifying determinants of practice.

Having many such lists may be confusing both for those who use them as checklists for identifying determinants of practice and for those interpreting the results of studies that have used different checklists. A common checklist that can be used internationally across different settings and types of targeted practices should reduce this confusion and facilitate clear and consistent reporting and interpretation of implementation research. This would facilitate the design of effective interventions and accumulation of knowledge on change of healthcare practice.

We have developed a checklist to identify determinants of practice to be used and evaluated in the project ‘Tailored Implementation for Chronic Diseases’ (TICD). While our focus is thus primarily on healthcare for patients with chronic diseases, we suggest that the checklist can be applied more broadly.

The comprehensive, integrated checklist of determinants of practice (the TICD Checklist) is intended as a screening tool to identify determinants that warrant further in-depth investigation. Subsequent investigation of determinants and the design of implementation strategies should focus on the factors that are most relevant for a specific recommendation. The aim of the checklist is to guide reflection and data collection on determinants of practice for a particular change, in order to explore which specific influences are most likely to be important. The idea is that this can facilitate tailoring more effective change interventions and the evaluation and reporting of tailored interventions. The checklist is intended to help both implementation researchers and people responsible for quality improvement in healthcare.

In this paper we describe the development of the TICD checklist of determinants of healthcare professional practice and present the checklist and accompanying worksheets that we have developed to facilitate its use.

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Tailored interventions to implement recommendations for elderly patients with depression in primary care: a study protocol for a pragmatic cluster randomised controlled trial

Eivind Aakhus, Ingeborg Granlund, Jan Odgaard-Jensen, Michel Wensing, Andrew D Oxman and Signe A Flottorp 

The prevalence of depression in the elderly is high and increases with age, even within the elderly. Elderly patients with depression are to a large extent treated in primary health care, and they prefer to be treated by their general practitioner. The risk that an elderly patient with depression develops a chronic episode is estimated to be approximately 30%. Depression in the elderly has a negative impact on quality of life, the episodes of the disease are longer, and the risks of hospitalisation and mortality are increased. Medical co-morbidities, which increase with advancing age, have a negative effect on treatment response and prognosis. Practitioners’ attitudes towards and experience with depressed elderly patients affect the probability of providing a patient with an adequate treatment strategy, and patients’ attitudes and beliefs towards the treatments might affect adherence and outcomes. Elderly patients with depression are less likely to be offered a course of psychotherapy, and GPs’ latency before reaching a decision with regard to a treatment strategy is longer. In Norway elderly patients are not referred to district psychiatric centres to the same degree as younger adults and when referred, the duration of contact for the treatment is shorter. To our knowledge, psychiatrists and psychologists in private practice treat elderly patients with depression to a very limited degree only. International studies indicate that general practitioners accurately diagnose about 50% of patients with depression, and approximately 40% of practice is in accordance with depression guidelines.

As there was no clinical practice guideline for managing depression in the elderly in Norway, and only a national guideline on the management of depression among adults in general, we conducted a systematic review, assessing 13 national and international clinical practice guidelines for managing depression in primary care. We identified all relevant recommendations for elderly patients with depression. We prioritised six of these recommendations for implementation.

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Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial

Elke Huntink, Naomi Heijmans, Michel Wensing and Jan van Lieshout

Cardiovascular disease (CVD) is an important cause of mortality and reduced quality of life worldwide. In The Netherlands, CVD is the leading cause of death for women and the second cause of death for men and imposes a heavy burden on both patients and health care, resulting in high expenditures. Studies have found that primary care for cardiovascular risk management (CVRM) is suboptimal for substantial numbers of patients. This is partly related to unfavourable lifestyles of many patients, which are difficult for patients to change and difficult for healthcare professionals to manage. Patient education and counselling in primary healthcare can moderately improve patients’ lifestyle and self-management but it remains a challenge to implement effective methods of patient education and counselling widely and sustainably in primary care.

The recommendations for diagnosis and treatment of CVD have been summarized in multidisciplinary clinical practice guidelines, including in The Netherlands, which will be the setting of our study. While it includes general recommendations on items of patient education, prevailing clinical guidelines pay little attention to how this is best organised in busy daily practice. In The Netherlands, the latter is provided in related guidelines, called ‘care standard’, which focuses on organisation of cardiovascular risk management. However, both the clinical guidelines and the ‘care standard’ do not provide detailed guidance for how to implement this in daily practice. A challenge therefore remains in encouraging patient self-management, informing patients, guiding patients towards a healthy lifestyle and cooperation between healthcare professionals.

Firstly, to enhance the current care, six key recommendations were selected from the Dutch multidisciplinary guideline for CVRM (Table  1). 

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A tailored implementation intervention to implement recommendations addressing polypharmacy in multimorbid patients: study protocol of a cluster randomized controlled trial

Cornelia Jäger, Tobias Freund Jost Steinhäuser, Stefanie Joos, Michel Wensing and Joachim Szecsenyi     

An increasing number of patients have multiple chronic conditions. Multimorbidity is associated with an increased likelihood of complex medication regimens often consisting of five or more different drugs, commonly defined as polypharmacy. With administration of increasing numbers of drugs, the risk of adverse drug reactions (ADRs) increases substantially thereby causing potentially avoidable hospital admissions and preventable deaths. Managing multimorbid patients with polypharmacy is particularly demanding in primary care practices (PCPs), as it requires coordination of multiple prescribers, profound pharmacological knowledge and intense monitoring of patients. 

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Evaluation of a tailored implementation strategy to improve the management of patients with chronic obstructive pulmonary disease in primary care: a study protocol of a cluster randomized trial

Maciek Godycki-Cwirko, Izabela Zakowska, Katarzyna Kosiek, Michel Wensing, Jaroslaw Krawczyk and Anna Kowalczyk     

Chronic obstructive pulmonary disease (COPD) remains a major health problem, strongly related to smoking. Despite the publication of practice guidelines on prevention and treatment, not all patients with the disease receive the recommended healthcare, particularly with regard to smoking cessation advice where applicable. We have developed a tailored implementation strategy for enhancing general practitioners' adherence to the disease management guidelines. The primary aim of the study is to evaluate the effects of this tailored implementation intervention on general practitioners' adherence to guidelines.

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Determinants of adherence to recommendations for depressed elderly patients in primary care: A multi-methods study. Scand J Prim Health Care 2014, 32:170-179.

Aakhus E., Oxman A.D., Flottorp S.A.         

Objective. It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression.
Design and setting. Group and individual interviews and a survey were conducted in Norway.
Method. Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants. Participants. Physicians and nurses from primary and specialist care, psychologists, researchers, and patients. Main outcome measures. Determinants of adherence to recommendations for depressed elderly patients in primary care.
Results. A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners' time constraints, the low prioritization of elderly patients with depression, and the patients' or relatives' wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions.
Implications. The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.

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Tailored Implementation of Evidence-Based Practice for Patients with Chronic Diseases. PLoS ONE 2014, 9:e101981.

Wensing M., Huntink E., van Lieshout J., Godycki-Cwirko M., Kowalczyk A., Jäger C., Steinhäuser J., Aakhus E., Flottorp S., Eccles M., Baker R.       

Background. When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries.
Methods. A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain.
Results. The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries.
Conclusion. The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

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Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implement Sci 2014, 9:102.

Krause J., Van Lieshout J., Klomp R., Huntink E., Aakhus E., Flottorp S., Jaeger C., Steinhaeuser J., Godycki-Cwirko M., Kowalczyk A., et al.       

Background. The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown.
Methods. The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease—COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants).
Results. A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming.
Conclusions.  Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects.


Stakeholders contributions to tailored implementation programs: an observational study of group interview methods. Implement Sci 2014, 9:185.

Huntink E., van Lieshout J., Aakhus E., Baker R., Flottorp S., Godycki-Cwirko M., Jager C., Kowalczyk A., Szecsenyi J., Wensing M.     

Background. Tailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases.
Methods. Participants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs.
Results. In total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers.
Conclusions. Group interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories.
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