TY - JOUR
AU - K. Austad
AU - K. L. Fantasia
AU - A. Mohanty
AU - K. C. Jones
AU - N. A. Bosch
AU - M. L. Drainoni
A1 - 
AB - BACKGROUND: Implementation strategies often fail to achieve their intended outcomes, yet limited methodological guidance exists for systematically understanding why strategies fail or how to adapt them for new contexts. Causal pathway diagrams (CPDs) are tools that map the mechanisms through which implementation strategies work. This study proposes a methodologic approach to use CPDs both retrospectively to understand implementation failure in one context and prospectively to inform adaptation for a new context. METHODS: We illustrate the proposed methodology using a case study of a failed implementation strategy bundle-including an electronic best practice alert and clinical decision support, provider education, and clinical champion-designed to improve metabolic-associated steatotic liver disease (MASLD) screening in a weight management clinic. Using mixed methods data and realist evaluation principles, we constructed CPDs guided by three theoretical frameworks (i-PARIHS, Theory of Planned Behavior, and Technology Acceptance Model) and post-intervention qualitative interviews to understand failure mechanisms. We then applied insights from these CPDs alongside qualitative interviews with primary care providers to develop predictive CPDs for implementing adapted strategies in the primary care setting. RESULTS: The retrospective CPDs revealed specific failure points not apparent during initial planning. The clinical decision support strategy failed because fundamental preconditions were unmet: only 54.2% of patients had recent laboratory results needed for automated calculations, and the alert placement misaligned with provider workflows. Provider education and clinical champion strategies were undermined by moderators including lack of confidence in the FIB-4 screening tool and competing clinical priorities. The prospective primary care CPDs identified necessary adaptations including replacing best practice alerts with integrated health maintenance reminders, adding content about MASLD complications and treatments to provider education, and selecting multiple champions to ensure adequate coverage. CONCLUSIONS: CPDs provide a systematic framework for transforming implementation failures into actionable insights for future intervention design. The integration of realist evaluation principles with multi-theoretical CPD development offers a replicable methodology for retrospective mechanistic failure analysis and context-adapted prospective implementation. This approach advances implementation science by moving beyond descriptive accounts toward rigorous understanding of how and why implementation strategies work across diverse settings.
AD - Department of Family Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, 850 Harrison Avenue Dowling 5, Boston, 02118, MA, United States. kirsten.austad@bmc.org.; Evans Center for Implementation & Improvement Sciences (CIIS), Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States. kirsten.austad@bmc.org.; Evans Center for Implementation & Improvement Sciences (CIIS), Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States.; Section of Endocrinology, Diabetes and Nutrition, Department of Medical Medicine, Boston, Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States.; Section of Gastroenterology, Department of Medicine, Boston Medical Center/Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, United States.; The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, United States.; Section of Infectious Diseases, Department of Medicine, Boston Medical Center/Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States.; Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States.
AN - 41462368
BT - Implement Sci Commun
C5 - General Literature
DA - Dec 29
DO - 10.1186/s43058-025-00844-4
DP - NLM
ET - 20251229
JF - Implement Sci Commun
LA - eng
N2 - BACKGROUND: Implementation strategies often fail to achieve their intended outcomes, yet limited methodological guidance exists for systematically understanding why strategies fail or how to adapt them for new contexts. Causal pathway diagrams (CPDs) are tools that map the mechanisms through which implementation strategies work. This study proposes a methodologic approach to use CPDs both retrospectively to understand implementation failure in one context and prospectively to inform adaptation for a new context. METHODS: We illustrate the proposed methodology using a case study of a failed implementation strategy bundle-including an electronic best practice alert and clinical decision support, provider education, and clinical champion-designed to improve metabolic-associated steatotic liver disease (MASLD) screening in a weight management clinic. Using mixed methods data and realist evaluation principles, we constructed CPDs guided by three theoretical frameworks (i-PARIHS, Theory of Planned Behavior, and Technology Acceptance Model) and post-intervention qualitative interviews to understand failure mechanisms. We then applied insights from these CPDs alongside qualitative interviews with primary care providers to develop predictive CPDs for implementing adapted strategies in the primary care setting. RESULTS: The retrospective CPDs revealed specific failure points not apparent during initial planning. The clinical decision support strategy failed because fundamental preconditions were unmet: only 54.2% of patients had recent laboratory results needed for automated calculations, and the alert placement misaligned with provider workflows. Provider education and clinical champion strategies were undermined by moderators including lack of confidence in the FIB-4 screening tool and competing clinical priorities. The prospective primary care CPDs identified necessary adaptations including replacing best practice alerts with integrated health maintenance reminders, adding content about MASLD complications and treatments to provider education, and selecting multiple champions to ensure adequate coverage. CONCLUSIONS: CPDs provide a systematic framework for transforming implementation failures into actionable insights for future intervention design. The integration of realist evaluation principles with multi-theoretical CPD development offers a replicable methodology for retrospective mechanistic failure analysis and context-adapted prospective implementation. This approach advances implementation science by moving beyond descriptive accounts toward rigorous understanding of how and why implementation strategies work across diverse settings.
PY - 2025
SN - 2662-2211
ST - Failing to succeed: advancing mechanistic understanding of implementation strategies through retrospective and prospective use of causal pathway diagrams
T1 - Failing to succeed: advancing mechanistic understanding of implementation strategies through retrospective and prospective use of causal pathway diagrams
T2 - Implement Sci Commun
TI - Failing to succeed: advancing mechanistic understanding of implementation strategies through retrospective and prospective use of causal pathway diagrams
U1 - General Literature
U3 - 10.1186/s43058-025-00844-4
VO - 2662-2211
Y1 - 2025
ER -