Professor of Public Health Policy and Management
Director of Global Center for Implementation Science
Dr. Shelley is a tenured Professor and Vice Chair for Research in the Department of Public Health Policy and Management and the founding Director of the Global Center for Implementation Science and Practice at the NYU School of Global Public Health. She conducts translational, population-based, and policy-relevant research that aims to accelerate dissemination and implementation of tobacco use treatment in safety net health care delivery systems and implementation of tobacco control policies. This research has been funded by the National Cancer Institute (NCI), National Institute of Drug Abuse, National Heart, Lung, Blood Institute, the Agency for Healthcare Research and Quality and the New York State Department of Health.
Dr. Shelley’s implementation research focuses on building the evidence for effective theory-driven strategies that target barriers to implementation and sustainability of evidence-based tobacco use treatment in primary care settings in the U.S and Viet Nam. Her research is also addressing the growing dual burden of noncommunicable and communicable diseases in LMICs and, specifically, the health impact on people living with HIV/AIDS. With funding from the NCI, Dr. Shelley is conducting a randomized controlled trial comparing the effectiveness of behavioral interventions and pharmacotherapy to improve cessation outcomes among people living with HIV/AIDs who use tobacco, and simultaneously, answering questions about the feasibility and effectiveness of implementation strategies to improve adoption of tobacco use treatment in HIV care settings in Viet Nam. An example of her policy research includes a recently completed NCI-funded study that evaluated the impact of the US federally mandated smoke free public housing policy on exposure to secondhand smoke and explored the implementation process to identify strategies with the potential to improve the process and maximize public health impact.
BS, University of Pennsylvania, PAMD, Mount Sinai School of Medicine, NYMPH, Health Policy and Management, Columbia University's Mailman School of Public Health, NY
Health Systems StrengtheningImplementation scienceTobacco CessationTobacco Policy
Analyzing Trajectories of Acute Cigarette Reduction Post-Introduction of an E-Cigarette Using Ecological Momentary Assessment DataGuttentag, A., Tseng, T. Y., Shelley, D., & Kirchner, T. (n.d.).
Journal titleInternational journal of environmental research and public health
Issue12AbstractElectronic cigarettes (ECs) may hold great potential for helping smokers transition off combustible cigarettes (CCs); however, little is known about the patterns that smokers follow when using an EC as a CC-substitute in order to ultimately reduce and quit smoking. Our primary aim in this study was to evaluate whether common patterns of CC use exist amongst individuals asked to substitute an EC for at least half of the CCs they would normally smoke. These patterns may eluci-date the immediate switching and reduction behaviors of individuals using ECs as a reduction/ces-sation tool. This analysis uses data from a randomized controlled trial of 84 adult smokers assigned to receive either 4.5% nicotine or placebo (0% nicotine) EC. Participants were advised to use the EC to help them reach a 50% reduction in cigarettes-per-day (CPD) within 3 weeks. Longitudinal trajectory analysis was used to identify CPD reduction classes amongst the sample; participants clus-tered into four distinct, linear trajectories based on daily CC use during the 3-week intervention. Higher readiness to quit smoking, prior successful quit attempts, and lower baseline CC consumption were associated with assignment into “more successful” CC reduction classes. ECs may be a useful mechanism to promote CC reduction. This study demonstrates that a fine-grained trajectory approach can be applied to examine switching patterns in the critical first weeks of an attempt.
Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement StudyNguyen, A. M., Cleland, C. M., Dickinson, L. M., Barry, M. P., Cykert, S., Duffy, F. D., Kuzel, A. J., Lindner, S. R., Parchman, M. L., Shelley, D. R., & Walunas, T. L. (n.d.).
Journal titleAnnals of family medicine
Page(s)255-261AbstractPURPOSE: Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings.METHODS: The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design.RESULTS: All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends.CONCLUSIONS: The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection. VISUAL ABSTRACT.
Could international human rights obligations motivate countries to implement tobacco cessation support?Meier, B. M., Raw, M., Shelley, D., Bostic, C., Gupta, A., Romeo-Stuppy, K., & Huber, L. (n.d.).
Journal titleAddictionAbstractBackground and aims: The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) seeks to realize the right to health through national tobacco control policies. However, few states have met their obligations under Article 14 of the FCTC to develop evidence-based policies to support tobacco cessation. This article examines how human rights obligations could provide a legal and moral basis for states to implement greater support for individuals to overcome their addiction to tobacco. Analysis: The United Nations (UN) has a well-established legal framework for promoting human rights, looking to the right to health to realize health autonomy. Where addiction undermines autonomy, it is widely acknowledged that addiction presents a significant barrier to cessation for individuals who use tobacco, undermining the right to health. The UN human rights system could, therefore, provide a complementary basis for monitoring state obligations under Article 14 of the FCTC, identifying challenges to FCTC implementation and motivating states to support tobacco cessation. Conclusions: The United Nations' human rights system offers a mechanism that could be used to monitor Framework Convention on Tobacco Control implementation in national policy, facilitating accountability for the progressive realization of cessation support.
Development of a homelessness risk screening tool for emergency department patientsDoran, K. M., Johns, E., Zuiderveen, S., Shinn, M., Dinan, K., Schretzman, M., Gelberg, L., Culhane, D., Shelley, D., & Mijanovich, T. (n.d.).
Journal titleHealth Services Research
Page(s)285-293AbstractObjective: To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes. Data sources: Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database. Study design: Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires. Data collection/extraction methods: Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching. Principal findings: Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry. Conclusions: Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.
Effectiveness of a Multicomponent Strategy for Implementing Guidelines for Treating Tobacco Use in Vietnam Commune Health CentersShelley, D., Cleland, C. M., Nguyen, T., Vandevanter, N., Siman, N., Van Minh, H., & Nguyen, N. (n.d.).
Journal titleNicotine and Tobacco Research
Page(s)196-203AbstractIntroduction: Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs). Aims and Methods: We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n = 26) in Vietnam. Arm 1 included training and a tool kit (eg, reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As + R). Provider surveys were conducted at baseline, 6 months, and 12 months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As. Results: Adoption of the 4As increased significantly across both study arms (all p <. 001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms, and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling. Conclusions: The study demonstrated the effectiveness of a multicomponent and multilevel strategy (ie, provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam. Implications: Improving implementation of evidence-based TDT guidelines is a necessary step toward reducing the growing burden of noncommunicable diseases and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam and offer a potentially scalable model for meeting Framework Convention on Tobacco Control Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a CHW for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.
Generating and Reporting Electronic Clinical Quality Measures from Electronic Health Records: Strategies from EvidenceNOW CooperativesRichardson, J. E., Rasmussen, L. V., Dorr, D. A., Sirkin, J. T., Shelley, D., Rivera, A., Wu, W., Cykert, S., Cohen, D. J., & Kho, A. N. (n.d.).
Journal titleApplied Clinical Informatics
Page(s)485-494AbstractBackground: Electronic clinical quality measures (eCQMs) from electronic health records (EHRs) are a key component of quality improvement (QI) initiatives in small-to-medium size primary care practices, but using eCQMs for QI can be challenging. Organizational strategies are needed to effectively operationalize eCQMs for QI in these practice settings. Objective: This study aimed to characterize strategies that seven regional cooperatives participating in the EvidenceNOW initiative developed to generate and report EHR-based eCQMs for QI in small-to-medium size practices. Methods: A qualitative study comprised of 17 interviews with representatives from all seven EvidenceNOW cooperatives was conducted. Interviewees included administrators were with both strategic and cooperative-level operational responsibilities and external practice facilitators were with hands-on experience helping practices use EHRs and eCQMs. A subteam conducted 1-hour semistructured telephone interviews with administrators and practice facilitators, then analyzed interview transcripts using immersion crystallization. The analysis and a conceptual model were vetted and approved by the larger group of coauthors. Results: Cooperative strategies consisted of efforts in four key domains. First, cooperative adaptation shaped overall strategies for calculating eCQMs whether using EHRs, a centralized source, or a hybrid strategy of the two. Second, the eCQM generation described how EHR data were extracted, validated, and reported for calculating eCQMs. Third, practice facilitation characterized how facilitators with backgrounds in health information technology (IT) delivered services and solutions for data capture and quality and practice support. Fourth, performance reporting strategies and tools informed QI efforts and how cooperatives could alter their approaches to eCQMs. Conclusion: Cooperatives ultimately generated and reported eCQMs using hybrid strategies because they determined neither EHRs alone nor centralized sources alone could operationalize eCQMs for QI. This required cooperatives to devise solutions and utilize resources that often are unavailable to typical small-to-medium-sized practices. The experiences from EvidenceNOW cooperatives provide insights into how organizations can plan for challenges and operationalize EHR-based eCQMs.
Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruptionHennein, R., Ggita, J., Ssuna, B., Shelley, D., Akiteng, A. R., Davis, J. L., Katamba, A., & Armstrong-Hough, M. (n.d.).
Journal titleGlobal Public Health
Page(s)1868-1882AbstractMany implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians’ opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians’ beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.
Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)McNeely, J., Mazumdar, M., Appleton, N., Bunting, A. M., Polyn, A., Floyd, S., Sharma, A., Shelley, D., & Cleland, C. M. (n.d.).
Journal titleSubstance Abuse
Page(s)564-572AbstractBackground: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based ‘Substance Use Screening and Intervention Tool (SUSIT)’. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control ‘screening only’ (SO) period to an intervention ‘SUSIT’ period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient’s screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.
Role of Local Evidence in Transferring Evidence-Based Interventions to Low- and Middle-Income Country Settings: Application to Global Cancer Prevention and ControlParascandola, M., Neta, G., Salloum, R. G., Shelley, D., & Rositch, A. F. (n.d.).
Journal titleJCO Global Oncology
Page(s)e2200054AbstractPURPOSE: Although the global burden of cancer falls increasingly on low- and middle-income countries (LMICs), much of the evidence for cancer prevention and control comes from high-income countries and may not be directly applicable to LMIC settings. In this paper, we focus on the following question: When the majority of the evidence supporting an evidence-based intervention or implementation strategy comes from high-income countries, what local, contextual evidence is needed when transferring and adapting an intervention or strategy to a specific LMIC setting? METHODS: We draw on an existing framework (the Population, Intervention, Environment, Transfer-T process model) for assessing transferability of interventions between distinct settings and apply the model to two case studies as learning examples involving implementation of tobacco use treatment guidelines and self sampling for human papillomavirus DNA in cervical cancer screening. RESULTS: These two case studies illustrate how researchers, policymakers, practitioners, and consumers may approach the need for local evidence from different perspectives and with different priorities. As uses and expectations around local evidence may be different for different groups, aligning these priorities through multistakeholder engagement in which all parties participate in defining the questions and cocreating the solutions is critical, along with promoting standardized reporting of contextual factors. CONCLUSION: Local, contextual evidence can be important for both researchers and practitioners, and its absence may hinder translation of research and implementation efforts across different settings. However, it is essential for researchers, practitioners, and other stakeholders to be able to clearly articulate the type of data needed and why it is important. In particular, where resources are limited, evidence generation should be prioritized to address real needs and gaps in knowledge.
Social relationships, homelessness, and substance use among emergency department patientsJurewicz, A., Padgett, D. K., Ran, Z., Castelblanco, D. G., McCormack, R. P., Gelberg, L., Shelley, D., & Doran, K. M. (n.d.).
Journal titleSubstance Abuse
Page(s)573-580AbstractBackground: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it’s not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.
Study protocol of a multiphase optimization strategy trial (MOST) for delivery of smoking cessation treatment in lung cancer screening settingsOstroff, J. S., Shelley, D. R., Chichester, L. A., King, J. C., Li, Y., Schofield, E., Ciupek, A., Criswell, A., Acharya, R., Banerjee, S. C., Elkin, E. B., Lynch, K., Weiner, B. J., Orlow, I., Martin, C. M., Chan, S. V., Frederico, V., Camille, P., Holland, S., & Kenney, J. (n.d.).
Issue1AbstractBackground: There is widespread agreement that the integration of cessation services in lung cancer screening (LCS) is essential for achieving the full benefits of LCS with low-dose computed tomography (LDCT). There is a formidable knowledge gap about how to best design feasible, effective, and scalable cessation services in LCS facilities. A collective of NCI-funded clinical trials addressing this gap is the Smoking Cessation at Lung Examination (SCALE) Collaboration. Methods: The Cessation and Screening to Save Lives (CASTL) trial seeks to advance knowledge about the reach, effectiveness, and implementation of tobacco treatment in lung cancer screening. We describe the rationale, design, evaluation plan, and interventions tested in this multiphase optimization strategy trial (MOST). A total of 1152 screening-eligible current smokers are being recruited from 18 LCS sites (n = 64/site) in both academic and community settings across the USA. Participants receive enhanced standard care (cessation advice and referral to the national Quitline) and are randomized to receive additional tobacco treatment components (motivational counseling, nicotine replacement patches/lozenges, message framing). The primary outcome is biochemically validated, abstinence at 6 months follow-up. Secondary outcomes are self-reported smoking abstinence, quit attempts, and smoking reduction at 3 and 6 months. Guided by the Implementation Outcomes Framework (IOF), our evaluation includes measurement of implementation processes (reach, fidelity, acceptability, appropriateness, sustainability, and cost). Conclusion: We will identify effective treatment components for delivery by LCS sites. The findings will guide the assembly of an optimized smoking cessation package that achieves superior cessation outcomes. Future trials can examine the strategies for wider implementation of tobacco treatment in LDCT-LCS sites. Trial registration: ClinicalTrials.govNCT03315910
Synchronous Home-Based Telemedicine for Primary Care: A ReviewLindenfeld, Z., Berry, C., Albert, S., Massar, R., Shelley, D., Kwok, L., Fennelly, K., & Chang, J. E. (n.d.).
Journal titleMedical Care Research and ReviewAbstractSynchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate.
Ten Common Structures and Processes of High-Performing Primary Care PracticesNguyen, A. M., Paul, M. M., Shelley, D. R., Albert, S. L., Cohen, D. J., Bonsu, P., Wyte-Lake, T., Blecker, S., & Berry, C. A. (n.d.).
Journal titleJournal of Public Health Management and Practice
Page(s)E639-E644AbstractStructures (context of care delivery) and processes (actions aimed at delivery care) are posited to drive patient outcomes. Despite decades of primary care research, there remains a lack of evidence connecting specific structures/processes to patient outcomes to determine which of the numerous recommended structures/processes to prioritize for implementation. The objective of this study was to identify structures/processes most commonly present in high-performing primary care practices for chronic care management and prevention. We conducted key informant interviews with a national sample of 22 high-performing primary care practices. We identified the 10 most commonly present structures/processes in these practices, which largely enable 2 core functions: mobilizing staff to conduct patient outreach and helping practices avoid gaps in care. Given the costs of implementing and maintaining numerous structures/processes, our study provides a starting list for providers to prioritize and for researchers to investigate further for specific effects on patient outcomes.
The Effect of Floor Height on Secondhand Smoke Transfer in Multiunit HousingGill, E., Anastasiou, E., Tovar, A., Shelley, D., Rule, A., Chen, R., Thorpe, L. E., & Gordon, T. (n.d.).
Journal titleInternational journal of environmental research and public health
Issue7AbstractSecondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (>15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m3). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m3; floors 8–14: 0.026 µg/m3; floors ≥15: 0.029 µg/m3; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m3; floors 8–14: 0.19 µg/m3; floors ≥15: 0.59 µg/m3; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.
A qualitative study of high-performing primary care practices during the COVID-19 pandemicAlbert, S. L., Paul, M. M., Nguyen, A. M., Shelley, D. R., & Berry, C. A. (n.d.).
Journal titleBMC Family Practice
Issue1AbstractBackground: Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices’ service delivery adaptations. Methods: We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study. Results: Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time. Conclusion: Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.
A taxonomy for external support for practice transformationSolberg, L. I., Kuzel, A., Parchman, M. L., Shelley, D. R., Perry Dickinson, W., Walunas, T. L., Nguyen, A. M., Fagnan, L. J., Cykert, S., Cohen, D. J., Balasubramanaian, B. A., Fernald, D., Gordon, L., Kho, A., Krist, A., Miller, W., Berry, C., Duffy, D., & Nagykaldi, Z. (n.d.).
Journal titleJournal of the American Board of Family Medicine
Page(s)32-39AbstractBackground: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. Methods: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. Results: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. Conclusions: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.
Adaptation and assessment of a text messaging smoking cessation intervention in Vietnam: Pilot randomized controlled trialJiang, N., Nguyen, N., Siman, N., Cleland, C. M., Nguyen, T., Doan, H. T., Abroms, L. C., & Shelley, D. R. (n.d.).
Journal titleJMIR mHealth and uHealth
Issue10AbstractBackground: Text message (ie, short message service, SMS) smoking cessation interventions have demonstrated efficacy in high-income countries but are less well studied in low- and middle-income countries, including Vietnam. Objective: The goal of the research is to assess the feasibility, acceptability, and preliminary efficacy of a fully automated bidirectional SMS cessation intervention adapted for Vietnamese smokers. Methods: The study was conducted in 3 phases. In phase 1, we adapted the SMS library from US-based SMS cessation programs (ie, SmokefreeTXT and Text2Quit). The adaptation process consisted of 7 focus groups with 58 smokers to provide data on culturally relevant patterns of tobacco use and assess message preferences. In phase 2, we conducted a single-arm pilot test of the SMS intervention with 40 smokers followed by in-depth interviews with 10 participants to inform additional changes to the SMS library. In phase 3, we conducted a 2-arm pilot randomized controlled trial (RCT) with 100 smokers. Participants received either the SMS program (intervention; n=50) or weekly text assessment on smoking status (control; n=50). The 6-week SMS program consisted of a 2-week prequit period and a 4-week postquit period. Participants received 2 to 4 automated messages per day. The main outcomes were engagement and acceptability which were assessed at 6 weeks (end of intervention). We assessed biochemically confirmed smoking abstinence at 6 weeks and 12 weeks. Postintervention in-depth interviews explored user experiences among a random sample of 16 participants in the intervention arm. Results: Participants in both arms reported high levels of engagement and acceptability. Participants reported using the program for an average of 36.4 (SD 3.4) days for the intervention arm and 36.0 (SD 3.9) days for the control arm. Four of the 50 participants in the intervention arm (8%) reset the quit date and 19 (38%) texted the keyword TIPS. The majority of participants in both arms reported that they always or usually read the text messages. Compared to the control arm, a higher proportion of participants in the intervention arm reported being satisfied with the program (98% [49/50] vs 82% [41/50]). Biochemically verified abstinence was higher in the intervention arm at 6 weeks (20% [10/50] vs 2% [1/50]; P=.01), but the effect was not significant at 12 weeks (12% [6/50] vs 6% [3/50]; P=.49). In-depth interviews conducted after the RCT suggested additional modifications to enhance the program including tailoring the timing of messages, adding more opportunities to interact with the program, and placing a greater emphasis on messages that described the harms of smoking. Conclusions: The study supported the feasibility and acceptability of an SMS program adapted for Vietnamese smokers. Future studies need to assess whether, with additional modifications, the program is associated with prolonged abstinence.
Barriers to engagement in implementation science research: A national surveyStevens, E. R., Shelley, D., & Boden-Albala, B. (n.d.).
Journal titleTranslational Behavioral Medicine
Page(s)408-418AbstractLow levels of engagement in implementation science (IS) among health researchers is a multifaceted issue. With the aim of guiding efforts to increase engagement in IS research, we sought to identify barriers to engagement in IS within the health research community. We performed an online survey of health researchers in the United States in 2018. Basic science researchers were excluded from the sample. IS engagement was measured by self-reported conduct of or collaboration on an IS study in the past 5 years. Potential barriers tested were (a) knowledge and awareness of IS, (b) attitudes about IS research, (c) career benefits of IS, (d) research community support, and (e) research leadership support. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics and potential barriers as predictors of IS engagement. Of the 1,767 health researchers, 49.7% indicated they engaged in an implementation study. Being able to define IS (aOR 3.42, 95%CI 2.68-4.36, p <. 001) and having attended IS training (aOR 3.77, 95%CI 2.96-4.81, p <. 001) were associated with engaging in IS research. Among other potential barriers tested, perceptions that engaging in IS would not be good for their career (aOR 0.29, 95%CI 0.2-0.41, p <. 001) was strongly associated with decreased engagement in IS research. Efforts to increase researcher familiarity with IS methods and foster support for IS within research communities, along with decreasing barriers to funding and publishing, are likely to be most effective for increasing engagement in IS research.
Cost Analysis of Community-Based Smoking Cessation Services in Vietnam: A Cluster-Randomized TrialQuynh Mai, V., Van Minh, H., Truong Nam, N., Thao Anh, H., Minh Van, N., Thi Trang, N., & Shelley, D. (n.d.).
Journal titleHealth Services Insights
Volume14AbstractThe study aimed to estimate the cost for developing and implementing 2 smoking cessation service delivery models that were evaluated in a 2-arm cluster randomized trial in Commune Health Centers (CHCs) in Vietnam. In the first model (4As) CHC providers were trained to ask about tobacco use, advise smokers to quit, assess readiness to quit, and assist with brief counseling. The second model included the 4As plus a referral to Village Health Workers (VHWs) who were trained to provide multisession home-based counseling (4As + R). An activity-based ingredients (ABC-I) costing approach with a healthcare provider perspective was applied to collect the costs for each intervention model. Opportunity costs were excluded. Costs during preparation and implementation phase were estimated. Sensitivity analysis of the cost per smoker with the included intervention’ activities were conducted. The cost per facility-based counseling session ranged from USD 9 to USD 11. Cost per home-based counseling session at 4As + R model was USD 4. The non-delivery cost attributed to supportive activities (eg, Monitoring, Logistic, Research, General training) was USD 107 per counseling session. Cost per smoker ranged from USD 6 to USD 451. The study analyzed and compared cost of implementing and scaling community-based smoking cessation service models in Vietnam.
E-cigarette use and beliefs among adult smokers with substance use disordersEl-Shahawy, O., Schatz, D., Sherman, S., Shelley, D., Lee, J. D., & Tofighi, B. (n.d.).
Journal titleAddictive Behaviors Reports
Volume13AbstractBackground: We explored characteristics and beliefs associated with e-cigarette use patterns among cigarette smokers requiring inpatient detoxification for opioid and/or alcohol use disorder(s). Methods: Adult cigarette smokers (≥18 years), admitted to inpatient detoxification for alcohol and/or opioid use disorder(s) in a safety-net tertiary referral center in New York City were surveyed in 2015 (n = 158). Descriptive statistics (proportions) were used to assess for demographic, clinical diagnosis, cigarette smoking patterns (exclusive and dual use of e-cigarettes). Chi-square, t-test statistics, and logistic regression models were used. Results: Among our sample of combustible cigarette users, 13.9% (n = 22) reported dual use with electronic cigarettes. Dual use did not differ by demographic or clinical variables. Compared to exclusive smokers, dual users were more likely to have tried to quit in the past year (Adjusted Odds ratio = 8.59; CI: 2.58, 28.35; p < 0.001). Dual smokers had significantly higher mean ratings perceiving that e-cigarettes can help people quit smoking compared to exclusive smokers (M = 3.7, SD= ±1.4 vs. M = 2.7, SD= ±1.5, p = 0.002) respectively. Dual users also preferred e-cigarettes over nicotine patches /gum for quitting (M = 3.7, SD= ±1.7 vs. M = 2.6, SD= ±1.6, p = 0.005). Conclusions: E-cigarette use seems to be appealing to a small proportion of cigarette smokers with SUD. Although, dual smokers seem to use e-cigarettes for its cessation premise, they don't appear to be actively seeking to quit. E-cigarettes may offer a more effective method for harm reduction, further evaluation of incorporating it within smoking cessation protocols among patients in addiction treatment is needed.
Effectiveness and Reach of the Primary Palliative Care for Emergency Medicine (PRIM-ER) Pilot Study: a Qualitative AnalysisFailed generating bibliography.Abstract
Journal titleJournal of general internal medicine
Page(s)296-304AbstractBackground: Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes. Objective: To understand the facilitators that contributed to the success of the Primary Palliative Care for Emergency Medicine (PRIM-ER) quality improvement pilot intervention. Design: Effectiveness was evaluated through semi-structured interviews. Reach outcomes were measured by percent of all full-time emergency providers (physicians, physician assistants, nurses) who completed the intervention education components and baseline survey assessing attitudes and knowledge on end-of-life care. Participants: Emergency medicine providers affiliated with two medical centers (N = 197). Interviews conducted with six key informants at both institutions. Approach: Interviews were recorded, transcribed, and analyzed using deductive and inductive approaches. Descriptive statistics include reach outcomes and baseline survey results. Key Results: Both sites successfully implemented all components of the intervention and achieved a high level (> 75%) of intervention reach. Two themes emerged as facilitators to successful effectiveness facilitators of PRIM-ER: (1) institutional leadership support and (2) leveraging established quality improvement (QI) processes. Institutional support included leveraging leadership with authority to (a) mandate trainings; (b) substitute PRIM-ER education for normally scheduled education; and (c) provide protected time to implement intervention components. Effectiveness was also enhanced by capitalizing on existing QI processes which included (a) leveraging interdisciplinary partnerships and communication plans and (b) monitoring performance improvement data. Conclusions: Capitalizing on strong institutional leadership support and established QI processes enhanced the reach and effectiveness of the PRIM-ER pilot. These findings will guide the PRIM-ER researchers in scaling up the intervention in the remaining 33 sites, as well as enhance the planning of other complex quality improvement interventions in clinical settings. Registration Details: ClinicalTrials.gov Identifier: NCT03424109; Grant Number: AT009844-01.
Effectiveness of an integrated engagement support system to facilitate patient use of digital diabetes prevention programs: Protocol for a randomized controlled trialLawrence, K., Rodriguez, D. V., Feldthouse, D. M., Shelley, D., Yu, J. L., Belli, H. M., Gonzalez, J., Tasneem, S., Fontaine, J., Groom, L. L., Luu, S., Wu, Y., McTigue, K. M., Rockette-Wagner, B., & Mann, D. M. (n.d.).
Journal titleJMIR Research Protocols
Issue2AbstractBACKGROUND: Digital diabetes prevention programs (dDPPs) are effective behavior change tools to prevent disease progression in patients at risk for diabetes. At present, these programs are poorly integrated into existing health information technology infrastructure and clinical workflows, resulting in barriers to provider-level knowledge of, interaction with, and support of patients who use dDPPs. Tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient engagement and adherence to these programs and improved health outcomes.OBJECTIVE: This study aims to use a rigorous, user-centered design (UCD) methodology to develop a theory-driven system that supports patient engagement with dDPPs and their primary care providers with their care.METHODS: This study will be conducted in 3 phases. In phase 1, we will use systematic UCD, Agile software development, and qualitative research methods to identify key user (patients, providers, clinical staff, digital health technologists, and content experts) requirements, constraints, and prioritization of high-impact features to design, develop, and refine a viable intervention prototype for the engagement system. In phase 2, we will conduct a single-arm feasibility pilot of the engagement system among patients with prediabetes and their primary care providers. In phase 3, we will conduct a 2-arm randomized controlled trial using the engagement system. Primary outcomes will be weight, BMI, and A 1c at 6 and 12 months. Secondary outcomes will be patient engagement (use and activity) in the dDPP. The mediator variables (self-efficacy, digital health literacy, and patient-provider relationship) will be measured. RESULTS: The project was initiated in 2018 and funded in September 2019. Enrollment and data collection for phase 1 began in September 2019 under an Institutional Review Board quality improvement waiver granted in July 2019. As of December 2020, 27 patients have been enrolled and first results are expected to be submitted for publication in early 2021. The study received Institutional Review Board approval for phases 2 and 3 in December 2020, and phase 2 enrollment is expected to begin in early 2021.CONCLUSIONS: Our findings will provide guidance for the design and development of technology to integrate dDPP platforms into existing clinical workflows. This will facilitate patient engagement in digital behavior change interventions and provider engagement in patients' use of dDPPs. Integrated clinical tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient adherence to these programs and improved health outcomes by addressing barriers faced by both patients and providers. Further evaluation with pilot testing and a clinical trial will assess the effectiveness and implementation of these tools.TRIAL REGISTRATION: ClinicalTrials.gov NCT04049500; https://clinicaltrials.gov/ct2/show/NCT04049500.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26750.
Health-Related Social Needs Among Emergency Department Patients with HIVGerber, E., Gelberg, L., Cowan, E., Mijanovich, T., Shelley, D., Gulati, R., Wittman, I., & Doran, K. M. (n.d.).
Journal titleAIDS and Behavior
Page(s)1968-1974AbstractLittle research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.
Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiativeLim, S., Wyatt, L. C., Mammen, S., Zanowiak, J. M., Mohaimin, S., Troxel, A. B., Lindau, S. T., Gold, H. T., Shelley, D., Trinh-Shevrin, C., & Islam, N. S. (n.d.).
Journal titleBMC Endocrine Disorders
Issue1AbstractBackground: A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. Methods: The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. Discussion: Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. Trial registration: This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.
Implementation Science to Improve Tobacco Cessation Services in Oncology CareFailed generating bibliography.Abstract
Journal titleJournal of the National Comprehensive Cancer Network : JNCCN
Page(s)S12-S15AbstractEvery patient with cancer deserves access to evidence-based tobacco cessation interventions as part of their routine oncology care. The NCI Cancer Moonshot funded the Cancer Center Cessation Initiative (C3I) to help establish and/or expand tobacco treatment programs at 52 NCI-designated Cancer Centers. Although this initiative has broadened the availability of tobacco treatment services across US cancer centers, the reach and utilization of these services remains low among patients. To help address the remaining gap between the availability and utilization of evidence-based treatments for tobacco use in the oncologic context, staff and investigators at C3I sites and the C3I Coordinating Center formed the C3I Implementation Science Working Group. The mission of this working group is to bring together clinicians, scientists, and policymakers who share a common interest in implementation science and treating tobacco use in the oncologic context to collaborate on projects aimed at shrinking the practice gap in this area. Through case study examples, we describe how the C3I Implementation Science Working Group is supporting efforts to identify effective ways to increase the utilization of evidence-based tobacco treatments within cancer treatment settings and promote the broader impact and long-term sustainability of C3I.