Implementing Research in the Clinical Setting

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This research project is also likely to have social and economic implications. ED overuse and overcrowding is a critical problem, and this project promotes a potential solution. There is a strong link between chronic disease and frequent ED use, driven largely by the medical and social complexity of these patients. Addressing ED overuse through CM redirects FUEDs to more appropriate forms of care, including primary care or substance abuse treatment, while remaining cost-effective. By developing a CM intervention program and studying its implementation at multiple sites throughout the French-speaking region of Switzerland, this project will provide insights and lessons for the broader use of CM interventions for health care services overuse throughout Switzerland.

Finally, the CM intervention targets a defined population— FUEDs —that is frequently highly vulnerable in terms of medical complexity, suffering from multiple chronic medical conditions, mental health and substance abuse treatment needs, as well as modifiable social determinants of health, including homelessness or low household income. Therefore, this project also addresses a medically and socially complex patient population with chronic health care and social service needs, as well as emphasizing improved communication and care coordination within interdisciplinary care teams.

There are several expected limitations in this current research project that were carefully considered while designing the study. A well-known limitation related to this design is regression to the mean. That said, interpretation of pre-post intervention changes on health outcomes will be made with caution.

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Next, self-reported data can be subject to reporting bias [ 52 , 53 ]. It can however, be reliable when measures are developed for and piloted on the target population, timeframes are manageable, confidentiality is ensured and the target behavior is not stigmatized [ 54 , 55 ]. The above conditions were carefully considered when designing the study, thereby minimizing the risk of self-report bias. Furthermore, recruitment and retention can be a challenge with the target population i.

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Procedures for maximizing study retention will therefore be inspired from the latter study. For instance, we will use incentives to help retention over time gift cards of increased value for each follow-up assessment completed: 10, 20 and 20 CHF for 3, 6 and month follow-up assessment. Additionally, specific steps will be taken to address any bias that may occur because of missing data as described previously.

Finally, although not known at this stage, the patient sample size will be larger than the hospital sample size; therefore, the implementation outcomes analyses will not have the same level of analysis and will mostly remain descriptive. To address this limitation, we will use mixed methods i. FUEDs represent a vulnerable population multiply affected by medical, psychological, social and substance-use problems accounting for a disproportionally high number of ED consultations.

A Model for Implementing Evidence-Based Practices More Quickly - NEJM Catalyst

There is, however, very limited knowledge about how to translate and implement such an intervention on a large scale to diverse clinical setting, including community hospitals and non-academic centers. In response, this research project aims to implement the CM intervention in several hospitals in French-speaking Switzerland while evaluating both implementation and clinical outcomes, thereby providing key insights into the mechanisms and processes for disseminating and implementing this intervention into broader practice.

The datasets are not publicly available due to privacy concerns but may be requested from the project principle investigator PB on reasonable request. VG conceived parts of the study design, conducted parts of the background literature review, provided scientific project management, assembled measures and drafted the manuscript. JM helped conceive the study and its design, provided supervision in implementation science methods and critically reviewed the manuscript. PB conceived the study and its design, drafted parts of the manuscript and critically reviewed the manuscript. All authors read and approved the manuscript.

This study was approved by the Swiss Ethics Committee on research involving humans of the Canton de Vaud project number: — Informed consent will be obtained from all participants. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Incorporating Implementation Research into Clinical Effectiveness Trials

Implementing a case management intervention for frequent users of the emergency department I-CaM : an effectiveness-implementation hybrid trial study protocol. Open Access. First Online: 11 January Part of the following topical collections: Organization, structure and delivery of healthcare. Background ED overcrowding represents a significant public health problem in developed countries. Methods This research project uses a hybrid study design assessing both implementation and clinical outcomes. Discussion This research project will contribute to implementation science by providing key insights into the processes of implementing CM into broader practice.

Background ED overcrowding is a common public-health concern in developed countries impacting both patients and health system outcomes [ 1 ]. Case management intervention effectiveness Previous research among FUEDs has established CM intervention effectiveness in improving housing and environmental quality of life and reducing homelessness [ 12 , 13 ]. The guiding implementation science framework Numerous conceptual frameworks exist to guide the design of research aiming to implement evidence-based practices in real-world settings.

The generic implementation framework GIF The GIF was developed based on a systematic review of the literature on conceptual implementation frameworks and aimed to provide guidance on the basic components required in implementation [ 28 ]. Design This research project features a Type 2-hybrid study design focusing on both implementation and clinical outcomes [ 27 ]. The CM intervention The CM intervention, as developed by our research team, typically includes the following steps. Study procedure, implementation strategies and ethics The whole project should be completed in 3.

We present below the study procedure over the five phases. We will use hereafter the term I-CaM research team to refer to staff working on the research project in the home institution, including 2 research assistants bachelor-level students in Medicine or Social Sciences , a research nurse nurse, MPH , a scientific collaborator Ph.

Implementation program components Description Implementation phase ED staff involvement Needs and interest assessment I-CaM team sends a survey to all eligible hospitals to assess health-providers needs and interests regarding the CM intervention. Implementation-related measures will target both the implementation process evaluation i. Table 2 Summary of the Implementation Measures by Phase. Quantitative measures assessing implementation process We will use an adapted Stages of Implementation Completion tool SIC [ 31 ] to assess implementation process by tracking the time of achievement of key implementation milestones over the whole implementation process.

Influencing factors will be evaluated among champions and case managers throughout the implementation process. Quantitative measures assessing the implementation effectiveness The adoption rate at the conclusion of the exploration phase i. Qualitative measures Implementation process will be further evaluated qualitatively during semi-structured interviews with champions and case managers examining influencing factors related the outer context e. Demographic variables Demographic variables e.

Vulnerability determinants Vulnerability determinants refer to dimensions that have been found to be positively related to FUEDs [ 21 ]. ED visits Number of ED visits over the past year will be extracted from medical records at baseline and at months. Significance This project addresses a critical area of ED health services overuse using a practical solution, while taking an innovative research approach that will contribute to the growing literature on this topic.

Limitations There are several expected limitations in this current research project that were carefully considered while designing the study. Acknowledgements The authors thank the staff of the participating hospital EDs. Availability of data and materials The datasets are not publicly available due to privacy concerns but may be requested from the project principle investigator PB on reasonable request.

Ethics approval and consent to participate This study was approved by the Swiss Ethics Committee on research involving humans of the Canton de Vaud project number: — Consent for publication Not applicable. Competing interests The authors declare that they have no competing interest. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Annuals of Emergency Medecine. CrossRef Google Scholar. State of emergency medicine in Switzerland: a national profile of emergency departments in International Journal Emergency Medecine.

Case management may reduce emergency department frequent use in a universal health coverage system: a randomized controlled trial. J Gen Intern Med.


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Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Academic Emergency Medecine. Defining frequent use of an urban emergency department. Emerg Med J. Systematic review of frequent users of emergency departments in non-US hospitals: state of the art. Eur J Emerg Med.

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Factors associated with frequent use of emergency services in a medical center. PubMed Google Scholar. LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med.


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Proximity and emergency department use: multilevel analysis using administrative data from patients with cardiovascular risk factors. Can Fam Physician. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Screening of mental health and substance users in frequent users of a general Swiss emergency department. BMC Emergency Medicine. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review.

Annuals of Emergency Medicine. Using case management in a universal health coverage system to improve quality of life of frequent emergency department users: a randomized controlled trial.


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Qual Life Res. The effectiveness of emergency department visit reduction programs: a systematic review. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med. PLoS One. Google Scholar. Advances in the conceptualization and measurement of health care empowerment: development and validation of the health care empowerment inventory.

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