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

项目摘要：尽管所有种族/民族对高血压(HTN)的认识和治疗都在增加 在美国，拉美裔美国人的血压控制率最低(拉美裔成年人：34%对43%)， 非西班牙裔黑人和白人成年人中有53%)。这些统计数据可以用不成比例的 与黑人和白人相比，拉丁裔对降压药的依从性更差。系统- 在初级保健环境中进行的水平干预改善了少数族裔的用药依从性 人口。我们的阿尤丹多一个拉丁裔Hipertensos Para mejorar adherencia a sus Medicamentos(ALMA)审判， 这表明这项建议显著改善了血压控制(51%比29%，p=0.04)和药物治疗 在对119名拉丁裔患者进行跟踪调查的样本中，患者的依从性(78%比72%，p=0.02)与加强的常规护理相比 在安全网的实践中。尽管它们有效，但像ALMA这样的循证干预通常需要长达17 需要几年时间才能转化为临床实践。迫切需要实施战略来加快 将循证干预措施转化为常规的“现实世界”安全网做法，以减少 脆弱人群中BP控制方面的差异。练习促进(PF)是一种加速 在医疗保健环境中实施循证干预。通过PF，辅导员与 医疗团队培养适应和实施循证系统变化和促进的技能 一种量身定制的方法，将这些变化整合到临床工作流程中。尽管有证据支持这一效果 用于预防性筛查(如乳房检查)的PF及其对实施循证医学的影响 在安全网实践中支持HTN管理的系统方法在很大程度上仍未经过测试。这 提案提供了一个机会，通过评估PF作为一种 在12个安全网家庭健康中心网络中实施ALMA的实用和可复制的策略 (FHC)在纽约市。使用混合方法设计，我们将分两个阶段进行这项研究：(1)预 实施阶段，我们将根据先前的工作，根据 执行研究综合框架，以促进在初级保健中心实施ALMA。 (2)实施阶段，在此期间，我们将在实用的整群随机对照试验中评估， PF战略与自我导向条件(即接收信息以实施 ALMA，但没有促进)对ALMA的实施保真度(主要结果)和临床结果 (次要结果)在650名患有不受控制的HTN的拉丁裔样本中，12个月后 FHC。将使用基于五个核心的混合方法方法来评估实施保真度 实施忠诚度的维度，如Proctor的实施成果框架所定义。临床 结果衡量标准包括血压控制(定义为140/90毫米汞柱)和服药依从性(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).