1. 1 Implementation of the BETTER 2 program Nicolette Sopcak, Carolina Aguilar, Kris Aubrey-Bassler, Richard Cullen, Melanie Heatherington, Donna Manca CPHA Conference Toronto May 28, 2014 A qualitative evaluation

2. 2 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.

3. 3 www.better.utoronto.ca Outline Background & Rationale The BETTER approach BETTER 2 - qualitative Methods Findings Conclusion Questions

4. 4 www.better.utoronto.ca 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)

5. 5 www.better.utoronto.ca Why Chronic Disease Prevention and Screening (CDPS)? Background & Rationale The BETTER approach BETTER 2 Implementation Methods Findings Conclusion Questions

6. 6 www.better.utoronto.ca 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)

7. 7 www.better.utoronto.ca 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)

8. 8 www.better.utoronto.ca The Prevention Practitioner Role 1)Invite patients (age 40-65) 2)First health check (medical history, identify eligible maneuvers) 1) Prevention visit with PP using shsshared shared decision making - personalized prevention prescription - links to other resources (e.g., dietician, physician, smoking cessation) 2)Re-assess & check-in with patients at follow-up (e.g., 3, 6, 12 months)

9. 9 www.better.utoronto.ca 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?

10. 10 www.better.utoronto.ca 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 1 systematic & comprehensive framework based on extensive review (synthesizes 19 existing frameworks, allows comparison with other implementation)

11. 11 www.better.utoronto.ca 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)

12. 12 www.better.utoronto.ca CFIR (5 domains) by Damschroder, Aron, Keith, Kirsh, Alexander, & Lowery (2009)

13. 13 www.better.utoronto.ca Preliminary Findings 1)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 1)Inner setting: Networks and communication, culture Team vs. single physician, relationships in team, Implementation climate (e.g., competition, relationships)

14. 14 www.better.utoronto.ca Preliminary Findings 4)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)

15. 15 www.better.utoronto.ca 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

16. 16 www.better.utoronto.ca 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

17. 17 www.better.utoronto.ca Thank you! Do you have any questions or comments?

18. 18 www.better.utoronto.ca References Damschroder, 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

19. 19 www.better.utoronto.ca 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.

20. 20 www.better.utoronto.ca BETTER trial publication Background & Rationale The BETTER approach BETTER 2 Implementation Methods Findings Conclusion

21. 21 www.better.utoronto.ca Algorithm

22. 22 www.better.utoronto.ca Bubble diagram

23. 23 www.better.utoronto.ca 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

24. 24 www.better.utoronto.ca Summary of Results Across Groups ControlPF onlyPP onlyPP & PF Mean Follow-up time (days)212214230235 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)

25. 25 www.better.utoronto.ca Summary Across Strata ControlPF onlyPP onlyPP & PF Mean Follow-up time (days)210211227245 Mean Number of Es (SD)9.47 (3.46)8.79 (3.43)9.56 (3.31)9.62 (3.45) Mean Number of Ms (SD)1.91 (1.81)2.35 (2.22)4.53 (2.86)5.27 (2.85) Mean SQUID (SD)0.20 (0.19)0.24 (0.22)0.47 (0.26)0.56 (0.25) Mental Health ControlPF onlyPP onlyPP & PF Mean Follow-up time (days)214215231229 Mean Number of Es (SD)8.85 (3.33)8.44 (3.05)8.54 (2.99)8.96 (2.95) Mean Number of Ms (SD)1.92 (1.73)2.71 (2.33)4.82 (2.52)5.28 (2.54) 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

26. 26 www.better.utoronto.ca BETTER 2 Logic model