Improving the Quality of Primary Care by Optimizing Implementation Research Reporting

• Implementation Science
• Primary Health Care

The need to understand the factors determining successful uptake of innovation in primary care settings, where there are a myriad of evidence-based preventive, diagnostic, and management interventions from which to select, is well recognized.¹ Yet, there is still substantial incongruence between recommendations and actual practice.^2⇓–4 How can proven procedures be applied in a systematic and sustainable way to all patients likely to benefit from them, without losing effectiveness? This is the question which the scientific methodologies of implementation research attempt to answer, shifting the focus from the “what” (evidence-based intervention to use) to the “how” (to adopt recommended care in routine primary care practice).⁵ The gap between what is actually done and what should be done exists across all health care sectors, but it is especially challenging in primary care, due to its inherent complexity and breadth.⁶ We know some of the challenges: implementing the “hundreds” of specialist clinical guidelines disseminated to primary care, working with limited resources, and the gap between the demands of implementation and the limited capacity of busy frontline medicine, which stifles change.⁷ Understanding implementation strategies and evaluating the effectiveness of evidence-based interventions when they are delivered in routine practice to unrestricted general populations in the context of typical community practice, are the remit of implementation research. “Real world laboratories,” such as the practice-based research networks and primary care centers, are crucial to this science.^8,9

Although implementation research has contributed over the past 15 years to our understanding of strategies for changing practice¹⁰, its potential is undermined by poor reporting of studies. Inconsistent terminology and taxonomy hinders indexing of implementation studies, making them hard to find when reviewing the literature.¹¹ Lack of detail on what was done and how change was achieved reduces the utility for those wishing to replicate positive findings¹², and limited descriptions of contexts make it difficult for readers to assess applicability to their primary care practice. The recent publication of the Standards for Reporting Implementation Studies (StaRI) provides a framework for comprehensive reporting of the results of implementation studies to promote further development of the field.¹³ This consensus effort was undertaken with the primary aim of providing authors with a checklist to improve and standardize reporting of implementation research, but there are messages for everyone seeking to change practice and improve quality of care. (see Table 1) The key concepts underlying StaRI (freely available via the EQUATOR website¹⁴) will influence the design and conduct of implementation research as well as inform the approach for achieving and measuring change in primary health care and population health improvement projects.

StaRI emphasizes the pivotal importance of context which may operate at many levels. For example, at an individual level, the approach to smoking cessation advice in a patient who perceives his cigarettes as something that are helping him cope with a domestic crisis is very different to the support we can offer the smoker who requests help on the first January to achieve a New Year's resolution. At an organizational level, the contextual characteristics of primary care influence the impact of implementation strategies. The relatively small organizations of primary care (compared with a large hospital) may make decisions to change easier to implement or, conversely, the geographic isolation of professionals working in small teams or centers scattered around the community may make it more difficult to address barriers to changing practice. Even within one health care system, primary care centers may be very diverse so that the strategies that will work in one practice may not be appropriate in another. StaRI highlights the need to monitor fidelity to the core content of both the intervention and implementation strategy, as well as report necessary adaptation to suit local organizational routines and professionals' and participants' preferences. Without a full description of fidelity to and adaptation of strategies and interventions, it is difficult to understand their impact on implementation and health outcomes and for readers to assess relevance to their particular situation.

StaRI distinguishes between the underutilized evidence-based intervention and the implementation strategy used to enhance adoption and sustainability in routine clinical care.¹⁵ For instance, to increase provision of an evidence-based health promotion intervention in a primary care center, apart from dissemination of guidelines, professional education, and training, we may consider strategies such as assessing “organizational readiness to change” to select participating centers; integration of information, communication, and decision support tools into the electronic health record; linkage with community organizations to extend reach; redistributing tasks among a multiprofessional team; and adjusting professional roles.¹⁶ This key distinction between the clinical intervention and the implementation strategy is crucial to conceptual thinking at the planning stage of quality improvement projects and informs the choice of outcomes measured as well as enabling clear reporting. The implication of these two different levels of actions and outcomes relevant to implementation may not immediately be clear to researchers used to working in a single level intervention model, but the companion explanation and elaboration document provides examples and additional detail.¹⁷

Fulfilling the reporting structures proposed by StaRI will be challenging for journals such as the Journal of the American Board of Family Medicine (JABFM), which will need to find innovative ways to meet the standards within the confines of their journal. It will require cooperation from the JABFM editorial staff on several fronts. First, they must instruct authors to use the format. Some authors will not be familiar with StaRI, and journals may need to direct them to resources such as the detailed explanation and elaboration document.¹⁷ StaRI promotes provision of all salient information in one document, so editors may need to maintain some flexibility in length constraints or encourage innovative ways to include detailed descriptions such as supplementary files or videos. Authors and readers too can play a critical role in the adoption of StaRI by providing feedback to JABFM editors on its utility and by encouraging others to adopt it as the standard format for communicating on these important issues. The choice is between accepting the unsatisfactory status quo or adopting strategies to improve reporting with a view to optimize the potential of implementation research to advance primary care.

• Received for publication May 11, 2017.
• Revision received September 10, 2017.
• Accepted for publication October 20, 2017.