Bridging the evidence-to-practice gap: Evaluating practice facilitation as a strategy to accelerate translation of a systems-level adherence intervention into safety net practices

项目总结：尽管所有种族/民族对高血压（HTN）的认识和治疗不断增加， 在美国，拉丁美洲人的血压（BP）控制率最低（拉丁美洲成年人：34%对43%， 非西班牙裔黑人和白色成人中为53%）。这些统计数字可能是由于不成比例的 与黑人和白人相比，拉丁美洲人对抗高血压药物的依从性较差。系统- 在初级保健环境中进行的水平干预改善了少数群体的药物依从性 人口。我们的Ayudando a Latinos Hipertensos帕拉Mejorar Adherencia a sus Medicamentos（阿尔马）试验， 这表明该建议显著改善了血压控制（51%对29%，p= 0.04）和药物治疗 在随访的119例拉丁美洲患者样本中，与加强常规护理相比，依从性（78 vs. 72%，p=.02） 在安全网实践中。尽管有效，但像阿尔马这样的循证干预措施往往需要17 多年来一直致力于临床实践。迫切需要执行战略，以加快 将循证干预措施转化为“真实的世界”安全网的常规做法， 在弱势人群中血压控制的差异。实践促进（PF）是一种方法，以加快 将循证干预措施落实到医疗机构。通过PF，协调员与 医疗保健团队发展技能，以适应和实施循证系统的变化，并促进 将这些变化整合到诊所工作流程中的定制方法。尽管有证据表明 用于预防性筛查的PF（例如，乳腺检查），其对实施循证医学的影响 在安全网实践中支持高危险性网络管理的系统方法在很大程度上仍未得到检验。这 该提案提供了一个机会，通过评估PF作为一种 在12个安全网家庭保健中心网络中实施阿尔马的实用和可复制战略 （FHC）在纽约市。采用混合方法设计，我们将分两个阶段进行这项研究：（1）预- 在实施阶段，我们将根据我们先前的工作， 实施研究综合框架，以促进阿尔马在FHC的实施。 (2)实施阶段，在此期间，我们将在一项实用的随机分组对照试验中评估， PF策略与自我导向条件相比的效果（即，收到执行资料 阿尔马但无促进）对阿尔马实施保真度（主要结局）和临床结局的影响 （次要结局）在12个月时，在650名接受治疗的不受控制的HTN拉丁裔样本中， FHC。将使用基于五个核心要素的混合方法评估实施保真度。 实施保真度的维度，如普罗克特的实施成果框架所定义的。临床 结果测量包括血压控制（定义为<140/90 mmHg）和药物依从性（评估 使用通过药房记录覆盖的天数比例）。

Project Summary: Despite increasing awareness and treatment of hypertension (HTN) across all racial/ethnic groups, Latinos have the lowest blood pressure (BP) control rates in the US (Latino adults: 34% vs. 43% and 53% in non-Hispanic black and white adults). These statistics may be explained by the disproportionately poorer adherence to antihypertensive medications among Latinos compared to blacks and whites. Systems- level interventions conducted in primary care settings have improved medication adherence in minority populations. Our Ayudando a Latinos Hipertensos Para Mejorar Adherencia a sus Medicamentos (ALMA) trial, which informs this proposal significantly improved both BP control (51 vs. 29%, p=.04) and medication adherence (78 vs. 72%, p=.02) compared to enhanced usual care in a sample of 119 Latino patients followed in a safety-net practice. Despite their efficacy, evidence-based interventions like ALMA often take up to 17 years to be translated into clinical practice. Implementation strategies are sorely needed to accelerate the translation of evidence-based interventions into routine “real world” safety-net practices, in order to reduce disparities in BP control in vulnerable populations. Practice facilitation (PF) is one method to accelerate the implementation of evidence-based interventions into healthcare settings. Through PF, a facilitator works with healthcare teams to develop the skills to adapt and implement evidence-based system changes and promotes a tailored approach to integrating those changes into the clinic workflow. Although evidence supports the effect of PF for preventive screenings (e.g., breast examination), its impact on implementing evidence-based systems approaches to support HTN management in safety-net practices remains largely untested. This proposal provides an opportunity to fill this evidence-to-practice gap by evaluating the effectiveness of PF as a practical and replicable strategy for implementing ALMA in a network of 12 safety-net Family Health Centers (FHCs) in New York City. Using a mixed-methods design, we will conduct this study in two phases: (1) A pre- implementation phase where we will refine the PF strategy, informed by our prior work, based on the Consolidated Framework for Implementation Research to facilitate the implementation of ALMA at the FHCs. (2) An implementation phase, during which we will evaluate, in a pragmatic cluster-randomized controlled trial, the effect of the PF strategy compared to a self-directed condition (i.e., receipt of information for implementing ALMA but no facilitation) on implementation fidelity (primary outcome) of ALMA and on clinical outcomes (secondary outcome) at 12 months among a sample of 650 Latinos with uncontrolled HTN cared for at the FHCs. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions of implementation fidelity, as defined by Proctor’s Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as <140/90 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records).