SPREAD-NET: PRactices Enabling Adapting and Disseminating in the safety NET

描述（由申请人提供）：国家的“安全网”社区卫生中心（CHCs）可以从实施干预措施中受益匪浅，这些干预措施在改善其他环境中的卫生保健过程和结果方面显示出了有效性。然而，缺乏对支持在CHCs中实施循证干预措施的最有效策略的了解，是及时传播临床创新的主要障碍。我们的长期目标是学习如何最好地将循证干预措施推广到全国的健康中心。为了实现这一目标，我们建议比较不同“支持策略”在帮助不同CHCs可持续实施干预以降低患者心血管疾病（CVD）事件风险方面的有效性。Kaiser Permanente开发并实施了“ALL倡议”（又名“ALL Initiative”）。ALL)是一种临床水平的干预措施，旨在提高患有糖尿病（DM）或心血管疾病的成人患者的比例，这些患者根据循证指南服用心脏保护药物（他汀类药物和ace抑制剂）。在Kaiser Permanente的综合护理环境中，ALL被证明是非常有效的，我们的团队在大量实施支持的帮助下，证明了在11个CHCs中成功实施ALL的可行性。本研究的下一步是确定在更多的chc中有效实施和维持这一干预所需的支持数量和类型。为此，我们将进行一项试验，其中30个CHCs被随机分组，在实施ALL时接受低、中或高强度的支持。我们将与OCHIN的CHC成员开展这项工作，OCHIN是一个社区卫生信息技术网络，拥有全国最大的CHC电子健康记录（EHR）平台之一；研究中心共享一个单一的、关联的电子病历。在实践变化模型和RE-AIM框架的指导下，我们将使用混合方法来：目标1：比较低、中、高强度策略如何有效地支持CHCs实施ALL，并评估与不同策略支持的实施相关的(i)符合指南的心脏保护处方和（ii）控制血压和低密度脂蛋白的临床患者比例的变化；目标2：评估战略在支持3年以上干预措施可持续性方面的有效性；目标3：确定在不同支持水平下与成功相关的临床特征。我们的团队包括CHC临床医生，以及传播和实施（D&I）、卫生经济学和卫生服务研究混合方法方面的专家。我们的研究旨在为未来ALL的实施以及其他已知的改善CHC合并DM / CVD患者预后的干预措施提供信息。我们的研究结果也可能对D&I科学产生很大的影响，通过比较实用的、可推广的方法来支持在CHCs和其他门诊环境中实施临床创新。

DESCRIPTION (provided by applicant): The nation's 'safety net' community health centers (CHCs) could benefit greatly from implementing interventions shown to be effective at improving health care processes and outcomes in other settings. However, a lack of knowledge about the most effective strategies for supporting implementation of evidence-based interventions in CHCs presents a major barrier to the timely dissemination of clinical innovations. Our long-term goal is to learn how best to disseminate evidence-based interventions into CHCs nationwide. Working towards that goal, we propose to compare the effectiveness of different 'support strategies' at helping diverse CHCs sustainably implement an intervention shown to reduce patients' cardiovascular disease (CVD) event risk. Kaiser Permanente developed and implemented the 'ALL Initiative' (a.k.a. 'ALL'), a clinic-level intervention designed to increase rates of adult patients with diabetes mellitus (DM) or CVD who are prescribed cardio-protective medications (statins and ACE-Inhibitors) according to evidence-based guidelines. After ALL was shown to be highly effective in Kaiser Permanente's integrated care setting, our team demonstrated the feasibility of adapting it for successful implementation in 11 CHCs - with the help of substantial implementation support. The next step in this body of research is to identify the amount and type of support needed to effectively implement and sustain this intervention in a greater number of CHCs. To that end, we will conduct a trial in which 30 CHCs are cluster-randomized to receive low, medium, or high-intensity support in implementing ALL. We will conduct this work with CHC members of OCHIN, a community health information technology network that hosts one of the nation's largest CHC electronic health record (EHR) platforms; study CHCs share a single, linked EHR. Guided by the Practice Change Model and RE-AIM framework, we will use mixed-methods to: Aim 1: Compare how effectively the low, medium, and high-intensity strategies support the CHCs' implementation of ALL, and assess change in rates of clinic patients with (i) guideline-appropriate cardioprotective prescriptions, and (ii) controlled blood pressure and low-density lipoprotein, as associated with implementation supported by the different strategies; Aim 2: Assess the strategies' effectiveness at supporting intervention sustainability over 3 years; and Aim 3: Identify clinic characteristics associated wit success at different levels of support. Our team includes CHC clinicians, and experts in dissemination and implementation (D&I), health economics, and health services research mixed-methods. Our study is designed to inform future implementation of ALL as well as other interventions known to improve outcomes among CHC patients with DM / CVD. Our results could also have high impact on D&I science, by comparing practical, generalizable methods for supporting the implementation of clinical innovations in CHCs and other ambulatory settings.