Authors:

Abstract

Introduction

Many effective interventions fail to translate into meaningful patient care outcomes across multiple contexts.  In fact, some estimates indicate that two-thirds of organizations' efforts to implement change fail. This can be linked to barriers to implementation, that may arise at multiple levels of healthcare: the patient level, the provider level, the organizational level, or the policy level.

Implementation strategies can be defined as sets of methods, techniques, and interventions used to enhance the adoption and integration of evidence-based innovations into usual care and their success is analysed in implementation science. We have studied literature on implementation strategies analysed throughout the Consolidated Framework on Implementation Research (CFIR). The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Each domain is subsequently structured in several constructs.

Methods

We carried out a search in SCOPUS and Web of Science (WOS) for publications that referenced CFIR in title/abstract and where published in English between 2009 and 2019. Inclusion criteria were studies that analysed implementation initiatives with CFIR. Settings could include healthcare, social care, employment or educational.

Screening was carried out by two independent researchers; decisions were cross-checked and disagreements were discussed and solved in a joint meeting. We collected and tabulated data on characteristics of the study (such as number of participants, CFIR analysed constructs), characteristics of the studied intervention under implementation (setting, country, number of sites/teams and type of professionals), results per construct and authors conclusions. Risk of bias was assessed with the Mixed methods appraisal tool (MMAT tool), section 3 for Quantitative non randomized trials

Results

Our search yielded 412 studies, after removing duplicates, 391 were excluded in screening. The inter-rater agreement was 86.43%, cases of no-coincidence were discussed and solved among the two researchers.

Most implementation studies where carried out in the United States and Australia. There were the same number of studies for implementation of clinical treatment innovations (n=9) and healthcare organizational innovations (n=9), and limited number in other contexts.

There was variability in the domains and constructs of the CFIR included in the literature, complicating general comparability. However, key constructs seem to influence implementation of innovations in all 5 domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation.

Discussion and conclusions

Our analysis is at a preliminary stage; however we can already identify the variability in the constructs highlighted as influent in different contexts at different levels of implementation (clinical or organizational).

Lessons learned

The relative low consistency in measuring the different constructs within CFIR complicates reaching transversal conclusions on implementation. The field would benefit from efforts to further homogenize.

Limitations

As any review, ours could have a bias in the search or extraction process, although mitigation strategies have been applied. We selected to study implementation through a single framework, which makes comparison easier but could potentially be complemented through other frameworks.

Suggestions for future research

To stimulate research on implementation efforts with shared measures.