Contribution to the literature
-
Although eHealth-facilitated integrated care models (eICMs) for chronically ill and transplant populations show promise in RCTs, real-world translation remains challenging, calling for sustainable implementation science-powered innovation.
-
Our newly-developed eHealth-facilitated ICM for allogeneic SteM cell transplantation (SMILe–ICM) originated at the intersection of implementation, behavioural, and computer science methods. It will be tested using a hybrid effectiveness-implementation RCT.
-
Our dual focus on implementation and effectiveness evaluation will inform optimisation of the SMILe-ICM while providing insights regarding the implementation pathway, which is understudied in chronically ill populations. Therefore, this study will inform future eICM adoption decisions.
Background
The SMILe project: a two-phase implementation science project
The SMILe-ICM
Classification according to the medical device regulation
Methods
Study aims
-
Aim 1 has two parts:
-
1a. to evaluate the SMILe-ICM’s effectiveness in view of one primary outcome—re-hospitalisation rate—and seven secondary outcomes—total healthcare utilization costs, total length of inpatient re-hospitalizations, medication non-adherence, treatment burden, health-related quality of life (HRQL), quality-adjusted life year (QALY), acute and chronic GvHD incidence and grade, and overall survival rate. Regarding the primary outcome, we hypothesise that, compared to the usual-care/control group, patients receiving the SMILe-ICM will have a lower re-hospitalisation rate. As for the secondary outcome set, compared to the control group, we expect to see lower total healthcare utilization costs, shorter lengths of re-hospitalizations, lower medication non-adherence (implementation phase of adherence [67]), less treatment burden, better HRQL, higher quality-adjusted life years (QALY), and equal medical outcomes (acute and chronic GvHD incidence, overall survival).
-
1b. to extend objective 1a by testing for a potential wane-out of the SMILe-ICM intervention effect in view of primary and secondary outcomes during the three-month post-intervention follow-up.
-
Aim 2 is to evaluate the SMILe–ICM’s bundle of implementation strategies and assess acceptability, appropriateness, feasibility, and fidelity (implementation outcomes) as well to evaluate the implementation pathway (as viewed by patients and health care professionals).
Study design
Context and targeted sites
Study participants, recruitment, and randomization
Sample
Sample size determination for aim 1
Recruitment
Randomization process
Sampling for aim 2
Usual care and intervention group
Usual care group (UCG)
Intervention group (IG)
Adaptations of the SMILe-ICM intervention to the Swiss setting
SMILe implementation strategies
Pre-Phase | Phase A | Phase B | Sustainment |
---|---|---|---|
Access new funding
| Conduct local needs assessment and consensus discussion |
Prepare/recruit patients/consumers to be active participants
| |
Develop aca- demic/clinical partnerships
| Develop academic, clinical & technical partnerships |
Ongoing consensus discussion and information of local opinion leaders
| |
Inform local opinion leaders
|
Visit other sites
|
Provide clinical supervision
| |
Identify early adopters
|
Provide local technical assistance
| ||
Organize clinical implementation teams |
Conduct and obtain patients’ and families feedback
| ||
Adapt and tailor to Swiss context
|
Remind clinicians
| ||
Develop/adapt educational material |
Spread of clinical innovation
| ||
Conduct educational meetings |
Stage implementation scale up
| ||
Revise professional roles | |||
Create new clinical teams |
The SMILe ICM’s logic model
Data collection and management
Measurement timepoints (T0 – Tz) and days post-Tx
| ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Variables
|
Measurements
|
T0a
|
T0b
|
T1
|
T2
|
T3
|
T4
|
T5
|
T6
|
T7
|
T8
|
Tz
|
−10
|
30
|
60
|
90
|
120
|
150
|
180
|
240
|
300
|
365
|
455
| ||
Primary outcome
| ||||||||||||
Re-hospitalisation rate (number of re-hospitalisations per patient year) | FIMA© (10 Items) [83] Medical Records, CRF | |||||||||||
Secondary outcomes
| ||||||||||||
Healthcare utilisation costs | FIMA© (10 Items) [83] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| ||
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| ||||
Length re-hospitalizations | FIMA© (10 Items) [83] Medical Records, CRF |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| ||
Medication adherence (implementation & persistence dimension [67]) | Electronic Monitoring: MEMS® Button [86] | |||||||||||
BAASIS© (implementation 4 items; persistence: 1 item) [87] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| ||
Treatment burden | PETS© (60 items) [88] |
X
|
X
|
X
|
X
| |||||||
Health-related Quality of Life | EQ-5D-5L© (5 items) [89] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
Quality-Adjusted Life Year (QALY) | EQ-5D-5L© (5 items) [89], value set for Germany EQ-VT v. 2.0 (116) |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
Incidence/grade chronic and acute GvHD | Medical record, CRF |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| ||
Overall survival rate | Medical record, CRF |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
Conditioning regimen | Medical record, CRF |
X
| ||||||||||
Donor match/type | Medical record, CRF |
X
| ||||||||||
Disease | Medical record, CRF |
X
| ||||||||||
Disease status at transplant | Medical record, CRF |
X
| ||||||||||
If death: Date and cause of death | Medical record, CRF |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
If relapse: Date of relapse | Medical record, CRF |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
Demographics
| ||||||||||||
Age | Medical Record, CRF |
X
| ||||||||||
Sex | Medical Record, CRF |
X
| ||||||||||
Education | Questionnaire (4 items) |
X
| ||||||||||
Living alone | Questionnaire (1 item) |
X
| ||||||||||
IMPLEMENTATION OUTCOME DATA (from intervention group / care coordinator team)
| ||||||||||||
Acceptability | AIM (4 items) [90] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
Appropriateness | IAM (4 Items) [90] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
Feasibility | FIM (4 items) [90] |
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
|
X
| |
Technology feasibility | N (days with data entry), N (technical problems) | |||||||||||
Intervention fidelity | N (visits), Minutes (visits), N (Behavioural Change Techniques) compared to protocol | |||||||||||
Intervention fidelity | 5% of intervention sessions will be randomly selected to be audiotaped and checked for protocol congruence |
Variables and measurement
Outcome variable(s) | Measure(s) and data collection procedures | Data source and reporter (when applicable) |
---|---|---|
Primary Outcome
| ||
Re-hospitalisation rate | Number of events after the initial post-alloSCT discharge per patient in the first year post-alloSCT | EHR |
Secondary Outcomes
| ||
Healthcare utilization costs | EHR | |
(2) Medical records and an adapted version of the generic FIMA© self-reporting questionnaire for elderly persons [83]: 7 items, asking retrospectively for number of visits to physicians, days/hours of ambulatory healthcare visits, days/hours of home care services received, days/hours of support by family caregivers, type(s) and duration(s) of rehabilitation therapy, reason(s) and duration(s) of inpatient days (including intensive care unit stays and/or emergency room visits), and current type of insurance. | Paper survey (pat.) | |
Length re-hospitalizations | (1) The total length of inpatient re-hospitalizations in the first year after alloSCT is the total number of hospitalized days (planned and unplanned) after initial post-alloSCT discharge until end of study, like reported in all medical reports and the generic FIMA© self-reporting questionnaire for elderly persons [83] | Paper survey (pat.) and EHR |
Medication adherence (implementation & persistence dimension [67]) | (2) Implementation & persistence dimension [67] will be assessed using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS©): a validated self-report measure assessing adherence to implementation issues (e.g., drug holidays; 4 items; yes/no) and persistence/discontinuation (1 item; yes/no) [87]. | Paper survey (pat.) |
(3) Daily intake (date and time) of immunosuppressive medication will be monitored electronically via the MEMS® Button, [86] which has been indicated previously as the preferred electronic monitoring device [63]. Patients will receive the button shortly before discharge and are instructed on how to use it at home until their immunosuppressants are discontinued. Data will be password-protected and stored on the MEMS® Adherence Software database, which provides an overview of the electronically compiled dosing history per patient [86]. | MEMS® Button [86] | |
Treatment burden | German version of the PETS© self-reporting questionnaire [88]: nine multi-item domain scales, each measuring the burden of one aspect of chronic illness treatment on a 4- or 5-point Likert-type response scales regarding a 4-week recall time frame: medical information (7 items); medications (7 items); medical appointments (3 items); health monitoring (2 items); interpersonal challenges (4 items); health care expenses (5 items); difficulty with health care services (7 items); role/social activity limitations due to self-management (6 items); and physical/mental exhaustion due to self-management (5 items). Raw domain scores are transformed to a standardised 0-to-100 metric, with higher scores indicating greater treatment burden. | Paper survey (pat.) |
Health-related Quality of Life | Measured using the EQ-5D-5L© [89], covering five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) and including the EQ–Visual Analogue Scale (VAS), on which individuals rate their overall perceived health state (scale of 0 to 100) | Paper survey (pat.) |
Quality-Adjusted Life Year (QALY) | Paper survey (pat.) | |
GvHD | Incidence and grade of chronic and acute GvHD | EHR |
Overall survival rate | Overall survival rate from start of study participation | EHR |
Conditioning regimen | Treatments used to prepare a patient for stem cell transplantation (e.g., chemotherapy, monoclonal antibody therapy, and radiation to the entire body) | EHR |
Donor match/type | Human leukocyte antigen (HLA) tissue type | EHR |
Disease | Primary disease | EHR |
If death | Date and cause of death | EHR |
If relapse | Date of relapse | EHR |
Effectiveness outcomes
Implementation outcomes and evaluation of implementation pathway
Outcome variable(s) | Measure(s) and data collection procedures | Data source and reporter (when applicable) |
---|---|---|
Acceptability from patient’s perspective
| Acceptability—reflecting the end users’ satisfaction with the intervention—will be assessed using the 4-item Acceptability of Intervention Measure (AIM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater acceptability [90]. | Paper survey (pat.) |
Appropriateness from patient’s perspective
| The intervention’s appropriateness, i.e., its perceived suitability to address problems within its target setting, will be assessed via the 4-item Intervention Appropriateness Measure (IAM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater appropriateness [90]. | Paper survey (pat.) |
Feasibility from patient’s perspective
| The intervention’s perceived suitability for everyday use – will be assessed with the Feasibility of Intervention Measure (FIM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater feasibility [90]. | Paper survey (pat.) |
Technology acceptability
| The ratio of the number of data entry days to the number of technological problems, will be a measured using data gathered via the SMILeApp. | SMILe monitoring data base (SMILe Care) |
Acceptability from CC’s perspective
| Acceptability—reflecting the end users’ satisfaction with the intervention—will be assessed using the 4-item Acceptability of Intervention Measure (AIM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater acceptability [90]. | Paper survey (CC) |
Appropriateness from CC’s perspective
| The intervention’s appropriateness, i.e., its perceived suitability to address problems within its target setting, will be assessed via the 4-item Intervention Appropriateness Measure (IAM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater appropriateness [90]. | Paper survey (CC) |
Feasibility from CC’s perspective
| The intervention’s perceived suitability for everyday use will be assessed with the Feasibility of Intervention Measure (FIM). Each item applies a 5-point Likert-type scale ranging from 1 (completely disagree) to 5 (completely agree) with higher scores indicating greater feasibility [90]. | Paper survey (CC) |
Intervention fidelity
| The gold standard measure of intervention delivery (observations/evaluations using prespecified criteria) [95] will be used: Intervention participants’ attendance as planned to face-to-face visits T0 – T8 (fully, partly or not at all) will be noted by the CC. Any deviation from the intervention protocol will be recorded in view of number, length, frequency of contacts, and delivered content. | CRF (RA) |
Implementation pathway
| To explore potential implementation process barriers and facilitators as well as problems experienced in its delivery, we will conduct focus group interviews with the alloSCT team including 10–15 health care professionals (i.e., haematologists, nurses, psycho-oncologists, management), who are involved in the in-patient and follow-up care, plus 10 individual intervention patient interviews. | Individual interviews (pat.) |
Focus group interviews (health care professionals) |
Analysis
-
Aim 1a: To determine whether hospitalisation rates (primary outcome) are reduced via the SMILe-ICM’s implementation, we will analyse any differences between IG and UCG rates by applying generalised linear mixed models (GLMM) [97]. The relevant variables (i.e., time, study group, and group x time interaction) will be entered into the models. Our targeted test statistic is the rate ratio by unconditional maximum likelihood estimation (Wald) as described by Rothman et al. [98] and implemented in epitools [99]. We will conduct intention-to-treat and per-protocol analysis. Two-sided significance will be set at 0.05. To analyze the target secondary outcomes over the course of time, descriptive analyses will be carried out and GLMM will be used to determine differences between the IG and UCG. Cost data will be collected and analysed quarterly. Overall survival will be analysed using the Kaplan-Meier method and the log-rank test. To analyse QALY, we will use the EQ-5D-5L© value set for Germany. The electronically compiled dosing history will be analysed using by applying GLMM, which account for dependence among observations from a single patient over time. The resulting estimates will be expressed as odds ratios (ORs) [100].
-
Aim 1b: To test a potential wane-out effect of the SMILe-ICM’s intervention effect over 3 months’ post-intervention follow-up, differences between the IG and the UCG will be determined by applying GLMM. This approach allows calculation of the main group and time effects, and of group-by-time interaction effects. Two-sided significance will be set at 0.05.
-
Aim 2: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) (implementation outcomes) [90] will be descriptively evaluated. Independent Student’s t-tests will be calculated to determine whether implementation outcome scores will change significantly within the IG over the study period. Concerning the analysis of the implementation pathway, field notes, audiotapes of interviews and mind maps of focus group discussions will serve as qualitative data. Transcript data will be stored and analysed in the ATLAS.ti 8 software package [101]. Individual interviews with patients will be thematically analysed following Braun et al.’s six-phase procedure—an approach using stepwise systematic and iterative processing of data to arrive at a meaningful description and interpretation [102]. During the focus group interviews with clinicians, key themes will be mind-mapped on a flipchart to help the researcher recall previous thoughts and summarise all of the focus groups’ input. Participants will have the opportunity to reflect on the maps and to add or change keywords [103]. After the final focus group session, all mind maps will be combined into a single meta-map using the Microsoft Visio Professional 2019 software [104]. We will then apply Mayring’s approach to qualitative content analysis [105].