Bridging the evidence-to-practice gap: a stepped-wedge cluster randomized controlled trial evaluating practice facilitation as a strategy to accelerate translation of a multi-level adherence intervention into safety net practices.

BACKGROUND: Poor adherence to antihypertensive medications is a significant contributor to the racial gap in rates of blood pressure (BP) control among Latino adults, as compared to Black and White adults. While multi-level interventions (e.g., those aiming to influence practice, providers, and patients) have been efficacious in improving medication adherence in underserved patients with uncontrolled hypertension, the translation of these interventions into routine practice within "real world" safety-net primary care settings has been inadequate and slow. This study will fill this evidence-to-practice gap by evaluating the effectiveness of practice facilitation (PF) as a practical and tailored strategy for implementing Advancing Medication Adherence for Latinos with Hypertension through a Team-based Care Approach (ALTA), a multi-level approach to improving medication adherence and BP control in 10 safety-net practices in New York that serve Latino patients. METHODS AND DESIGN: We will conduct this study in two phases: (1) a pre-implementation phase where we will refine the PF strategy, informed by the Consolidated Framework for Implementation Research, to facilitate the implementation of ALTA into routine care at the practices; and (2) an implementation phase during which we will evaluate, in a stepped-wedge cluster randomized controlled trial, the effect of the PF strategy on ALTA implementation fidelity (primary outcome), as well as on clinical outcomes (secondary outcomes) at 12 months. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions outlined by Proctor's Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as BP< 130/80 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records). DISCUSSION: The study protocol applies rigorous research methods to identify how implementation strategies such as PF may work to expedite the translation process for implementing evidence-based approaches into routine care at safety-net practices to improve health outcomes in Latino patients with hypertension, who suffer disproportionately from poor BP control. By examining the barriers and facilitators that affect implementation, this study will contribute knowledge that will increase the generalizability of its findings to other safety-net practices and guide effective scale-up across primary care practices nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.

The cardiovascular in-training examination: development, implementation, results, and future directions.

BACKGROUND: The American College of Cardiology (ACC), in collaboration with the National Board of Medical Examiners (NBME), developed the first standardized in-training examination (ITE) for cardiovascular disease fellows-in-training (FITs). In addition to testing knowledge, this examination uses the newly developed ACC Curricular Milestones to provide specific, competency-based feedback to program directors and FITs. The ACC ITE has been administered more than 5,000 times since 2011. OBJECTIVES: This analysis sought to report the initial experience with the ITE, including feasibility and reliability of test development and implementation, as well as the ability of this process to provide useful feedback in key content areas. METHODS: The annual ACC ITE has been available to cardiovascular disease fellowship programs in the United States since 2011. Questions for this Web-based, secure, multiple-choice examination were developed by a group of cardiovascular disease specialists and each question was analyzed by the NBME to ensure quality. Scores were equated and standardized to allow for comparability. Trainees and program directors were provided detailed feedback, including a list of the curricular competencies tested by those questions answered incorrectly. RESULTS: The ITE was administered 5,118 times. In 2013, the examination was taken by 1,969 fellows, representing 194 training programs. Among the 3 training years, there was consistency in the examination scores. Total test scores and scores within each of the content areas increased with each FIT year (there was a statistically significant difference in each cohort's average scale score across administration years). There was also significant improvement in examination scores across the fellowship years. CONCLUSIONS: The ACC ITE is a powerful tool available to all training programs to assess medical knowledge. This examination also delivers robust and timely feedback addressing individual knowledge gaps, and thus, may serve as a basis for improving training curricula.

Condiciones teórico-metodológicas para la realización de un diagnóstico territorial de salud mental en Santa Fe de Bogotá / Theoretical-methodological conditions for the realization of a territorial mental health diagnosis in Santa Fe de Bogota

Introducción Este trabajo se basa en la experiencia piloto de salud mental que se realiza enTunjuelito (Centro de Salud Mental Comunitaria San Benito) y pretende determinar las condiciones teórico-metodológicas para un diagnóstico de salud mental en Santa Fe de Bogotá. Objetivo Establecer una metodología para describir el estado de salud mental y explorar las variables asociadas a los indicadores propuestos mediante estrategias cuantitativas y cualitativas. Metodología Mediante el trabajo interdisciplinario de expertos se obtuvieron tanto las definiciones teórico-metodológicas como los resultados finales. La estrategia metodológica general para la obtención de instrumentos cuantitativos y cualitativos tuvo los siguientes procesos: 1. acuerdo y definición de constructos teóricos: 2. definición de variables e indicadores: 3. elaboración de instrumentos experimentales; 4- consulta con grupo de clínicos y equipo: 5. aplicación piloto, y 6. calibración (modelo de Rash para la cuantitativa) y ajuste. El diseño muestral se plantea como una propuesta costo-efectiva considerando grupos de localidades. Resultados El producto final es un análisis del marco teórico, el diseño de la muestra por grupos de localidades que conforman regionales en Bogotá y una metodología que combina técnicas cualitativas y cuantitativas. Conclusiones La construcción interdisciplinaria empleando diferentes metodologías mejora la posibilidad de recoger información fiable sobre condiciones de salud mental. La definición de salud mental debe incluir aspectos positivos y no sólo prevalencia de enfermedades. El diseño muestral por grupos de localidades para estudios de prevalencia aporta al proceso de regionalización del sector salud.

Introduction This work is based on the mental health pilot experience carried out inTunjuelito (San Benito Community Mental Health Center) and aims to determine the theoretical and methodological conditions for a mental health diagnosis in Santa Fe de Bogotá. Objective To establish a methodology to describe the state of mental health and explore the variables associated with the proposed indicators through quantitative and qualitative strategies. Methodology Through the interdisciplinary work of experts, both the theoretical-methodological definitions and the final results were obtained. The general methodological strategy for obtaining quantitative and qualitative instruments had the following processes: 1. agreement and definition of theoretical constructs: 2. definition of variables and indicators: 3. elaboration of experimental instruments; 4- consultation with the group of clinicians and team: 5. pilot application, and 6. calibration (Rash model for the quantitative) and adjustment. The sample design is proposed as a cost-effective proposal considering groups of localities. Results The final product is an analysis of the theoretical framework, the sample design by groups of localities that make up the Bogota region, and a methodology that combines qualitative and quantitative techniques. Conclusions The interdisciplinary construction using different methodologies improves the possibility of collecting reliable information on mental health conditions. The definition of mental health should include positive aspects and not only prevalence of diseases. The sample design by groups of localities for prevalence studies contributes to the regionalization process of the health sector.