Literature Collection

BACKGROUND: Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators) of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. METHODS: We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or federally qualified health centers (FQHCs). We report results with a conceptual model integrating two frameworks: (1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and (2) the Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. RESULTS: Thirty-one clinicians, including 18 (58%) primary care and 13 (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. CONCLUSIONS: Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.

BACKGROUND: Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. METHODS: We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or Federally Qualified Health Centers (FQHCs). We report results with a conceptual model integrating two frameworks: 1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and 2) The Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. RESULTS: Thirty-one clinicians, including thirteen eighteen (58%) primary care and (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. CONCLUSIONS: Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.

The federal Ending the HIV Epidemic (EHE) initiative was created to reduce new US HIV infections, largely through pre-exposure prophylaxis and HIV treatments that reduce HIV transmissibility to zero. Behavioral health disorders (mental health and substance use) remain significant barriers to achieving EHE goals. Addressing behavioral health (BH) disorders within HIV primary care settings has been promoted as a critical EHE strategy. Implementation of efficacious HIV-BH care integration and its impact on HIV-related health outcomes is not well documented. In a federally-funded, exploratory phase implementation science study, we used the Collective Impact Framework to engage partners in seven EHE jurisdictions about the feasibility, acceptability, and sustainability of implementing HIV-BH integration interventions within local HIV settings. Partners concluded that full integration will remain the exception unless health systems invest in collaborative practice, professional training, appropriate health technology, and inter-system communication. Partners supported smaller incremental improvements including transdiagnostic approaches to reinforce each team member's sense of value in the shared endeavor. This early phase implementation science study identified research and implementation gaps that are critical to fill to end the HIV epidemic. Both the Collective Impact Framework and implementation science show promise for guiding future implementation of evidence-based HIV-BH intervention integration.

BACKGROUND: Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing. METHODS/DESIGN: We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. DISCUSSION: To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD86835.

INTRODUCTION: A significant risk for overdose among patients prescribed opioid medications is co-use of alcohol. Community pharmacies are underutilized as a resource to prevent and address co-use. The barriers and facilitators that promote or impede the adoption of universal alcohol screening and intervention at point of opioid medication dispensing are unknown. We assessed community pharmacy leaders, pharmacists, and technician's perceptions towards the implementation of a pharmacy-based screening/intervention for the co-use of opioids and alcohol among patients. METHODS: We conducted a multi-method study that included one-time key informant interviews combined with a close-ended survey to inform our understanding of pharmacy system/practice-level barriers and facilitators for universal screening and intervention. Participants were recruited from Utah and Tennessee and were required to have active employment as pharmacy leaders, pharmacists, or technicians, be English-speaking, and believe they could provide feedback regarding co-use screening and intervention within community pharmacies. Interviews used the Consolidated Framework for Implementation Research and the Organizational Readiness for Implementing Change assessment. Qualitative analysis included both inductive and deductive coding. Themes followed a cycle of open, initial coding whereby codes were derived inductively from the data. RESULTS: Themes from interviews (N = 68) included a) emphasizing a need to overcome the stigma associated with patients who engage in co-use and a mindset shift to treat the challenges and risks associated, b) need for corporate-level support, management buy-in, and c) appropriate technology to support the workflow including system-wide changes to support the integration of medication therapy management services within community pharmacies. However, barriers were offset by pharmacists eager to understand their role in screening patients and reiterated a focus on patient-centered care to achieve this goal. From the ORIC assessment, 75 % (n = 51) of respondents reported that community pharmacy staff wanted to implement the screening and intervention, and 69.1 % (n = 47) reported motivation to implement the screening and intervention. Finally, 67.6 % (n = 46) felt that community pharmacies are committed to implementing the screening and intervention, but only 10.3 % (n = 7) expressed strong support to do "whatever it takes" to implement the screening and intervention. CONCLUSION: These results provide critical insights into implementation strategies for the adoption of brief intervention by community pharmacists. These data are foundational to developing strategies for a powered trial and possible future system/practice-level implementation of universal alcohol screening and intervention for co-use.