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Concept: Initiative

171

BACKGROUND: Although significant advances have been made in implementation science, comparatively less attention has been paid to broader scale-up and spread of effective health programs at the regional, national, or international level. To address this gap in research, practice and policy attention, representatives from key stakeholder groups launched an initiative to identify gaps and stimulate additional interest and activity in scale-up and spread of effective health programs. We describe the background and motivation for this initiative and the content, process, and outcomes of two main phases comprising the core of the initiative: a state-of-the-art conference to develop recommendations for advancing scale-up and spread and a follow-up activity to operationalize and prioritize the recommendations. The conference was held in Washington, D.C. during July 2010 and attended by 100 representatives from research, practice, policy, public health, healthcare, and international health communities; the follow-up activity was conducted remotely the following year. DISCUSSION: Conference attendees identified and prioritized five recommendations (and corresponding sub-recommendations) for advancing scale-up and spread in health: increase awareness, facilitate information exchange, develop new methods, apply new approaches for evaluation, and expand capacity. In the follow-up activity, ‘develop new methods’ was rated as most important recommendation; expanding capacity was rated as least important, although differences were relatively minor. SUMMARY: Based on the results of these efforts, we discuss priority activities that are needed to advance research, practice and policy to accelerate the scale-up and spread of effective health programs.

Concepts: Health care, Health economics, Public health, Health, Policy, Stakeholder, Initiative, Avengers: The Initiative

96

Implementation studies are often poorly reported and indexed, reducing their potential to inform initiatives to improve healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aimed to develop guidelines for transparent and accurate reporting of implementation studies. Informed by the findings of a systematic review and a consensus-building e-Delphi exercise, an international working group of implementation science experts discussed and agreed the StaRI Checklist comprising 27 items. It prompts researchers to describe both the implementation strategy (techniques used to promote implementation of an underused evidence-based intervention) and the effectiveness of the intervention that was being implemented. An accompanying Explanation and Elaboration document (published in BMJ Open, doi:10.1136/bmjopen-2016-013318) details each of the items, explains the rationale, and provides examples of good reporting practice. Adoption of StaRI will improve the reporting of implementation studies, potentially facilitating translation of research into practice and improving the health of individuals and populations.

Concepts: Improve, Evidence-based medicine, Report, Research, Implementation, Explanation, Potential, Initiative

8

There are approximately 426,000 people residing within care homes in the UK. Residents often have complex trajectories of dying, which make it difficult for staff to manage their end-of-life care. There is growing recognition for the need to support care homes staff in the care of these residents with increased educational initiatives. One educational initiative is The Six Steps to Success programme.

Concepts: Death, Life, United Kingdom, End-of-life care, Anarchy in the U.K., Referendum, Initiative, Avengers: The Initiative

6

Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.

Concepts: Society, Initiative, Avengers: The Initiative

6

Hugo Chávez dominated the Venezuelan electoral landscape since his first presidential victory in 1998 until his death in 2013. Nobody doubts that he always received considerable voter support in the numerous elections held during his mandate. However, the integrity of the electoral system has come into question since the 2004 Presidential Recall Referendum. From then on, different sectors of society have systematically alleged electoral irregularities or biases in favor of the incumbent party. We have carried out a thorough forensic analysis of the national-level Venezuelan electoral processes held during the 1998-2012 period to assess these complaints. The second-digit Benford’s law and two statistical models of vote distributions, recently introduced in the literature, are reviewed and used in our case study. In addition, we discuss a new method to detect irregular variations in the electoral roll. The outputs obtained from these election forensic tools are examined taking into account the substantive context of the elections and referenda under study. Thus, we reach two main conclusions. Firstly, all the tools uncover anomalous statistical patterns, which are consistent with election fraud from 2004 onwards. Although our results are not a concluding proof of fraud, they signal the Recall Referendum as a turning point in the integrity of the Venezuelan elections. Secondly, our analysis calls into question the reliability of the electoral register since 2004. In particular, we found irregular variations in the electoral roll that were decisive in winning the 50% majority in the 2004 Referendum and in the 2012 Presidential Elections.

Concepts: Voting, Elections, Election, Referendum, Voting system, Initiative, Representative democracy, By-election

3

Participatory health initiatives ideally support progressive social change and stronger collective agency for marginalized groups. However, this empowering potential is often limited by inequalities within communities and between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of power in rural north India.

Concepts: India, Urdu, Madhya Pradesh, Hindi, Initiative, North India, Haryana, Progressive Era

2

Electronic Palliative Care Coordination Systems (EPaCCS) are England’s pre-eminent initiative in enabling advance care planning and improved communication and coordination at the end of life. EPaCCS have been under development for 8 years after being proposed, as Locality Registers, in the 2008 End of Life Care Strategy for England. EPaCCS are electronic registers or tools and processes for sharing data which aim to enable access to information about dying patients. Striking outcomes have been reported around EPaCCS, such as 77.8% of ‘Coordinate My Care’ patients dying in their preferred place. EPaCCS have, however, been extremely challenging to develop and implement, with many projects remaining continuously ‘under development’ or folding. They also continue to be suboptimally integrated with other data sharing initiatives. Rigorous research is non-existent.

Concepts: Game theory, Patient, Life, Palliative care, Enabling, Human Development Index, Development, Initiative

2

The Bundled Payments for Care Improvement initiative is a federally funded innovation model mandated by the Affordable Care Act. It is designed to help transition Medicare away from fee-for-service payments and toward bundling a single payment for an episode of acute care in a hospital and related postacute care in an appropriate setting. While results from the initiative will not be available for several years, current data can help provide critical early insights. However, little is known about the participating organizations and how they are focusing their efforts. We identified participating hospitals and used national Medicare claims data to assess their characteristics and previous spending patterns. These hospitals are mostly large, nonprofit, teaching hospitals in the Northeast, and they have selectively enrolled in the bundled payment initiative covering patient conditions with high clinical volumes. We found no significant differences in episode-based spending between participating and nonparticipating hospitals. Postacute care explains the largest variation in overall episode-based spending, signaling an opportunity to align incentives across providers. However, the focus on a few selected clinical conditions and the high degree of integration that already exists between enrolled hospitals and postacute care providers may limit the generalizability of bundled payment across the Medicare system.

Concepts: Health insurance, Patient, Hospital, Integral, Payment, Teaching hospital, Initiative, Business terms

2

Background:The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer.Methods:A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not.Results:Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme’s effectiveness.Conclusions:Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads.British Journal of Cancer advance online publication, 3 March 2015; doi:10.1038/bjc.2015.43 www.bjcancer.com.

Concepts: Better, General practitioner, National Health Service, Primary care, Family medicine, Initiative, Avengers: The Initiative, Direct democracy

1

Many countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have led to a general policy initiative to promote harmonization across programs, there is a need for countries to develop a more coherent and organized approach to CHW programs and to generate evidence about the most efficient and effective strategies to ensure their optimal, sustained performance.

Concepts: Health care, Referendum, Initiative, Avengers: The Initiative