Background
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Objective 1: determine types of studies that use the CFIR.
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Objective 2: determine how the CFIR has been applied, including depth of application.
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Objective 3: determine the contribution of the CFIR to implementation research.
Methods
Search strategy
Inclusion and exclusion criteria
Study selection process
Data extraction and analysis
Research objective | Operationalization of objective (codes for analysis) |
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Objective 1: determine the types of studies that use the CFIR | General study characteristics, including: • Research objective • Setting • Unit of analysis (e.g., organization- or provider-level) • Phase of implementation (pre-, during, or post-implementation) • Study design and methods (qualitative, quantitative, or mixed-methods) |
Objective 2: determine how the CFIR is being applied, including depth of application | Depth of CFIR application, including: • How the CFIR was used (e.g., to guide data analysis, data collection, or both) • Rationale of selection of CFIR constructs, as well as which CFIR constructs were selected and used • Investigation of outcomes, including implementation effectiveness outcomes, and measurement of association between CFIR constructs and outcomes |
Objective 3: determine the contribution of the CFIR to implementation research | General commentary about validity and utility of the CFIR, based on three questions posed by Damschroder et al. in their seminal CFIR publication [3], which included: • Coherence of CFIR terminology • Whether the CFIR promotes comparison across studies • Whether the CFIR stimulates new theoretical development |
Results
Objective 1: types of studies that have used the CFIR
Author | Research objective | Methods | Unit of analysis | Phase of implementation |
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Acosta et al. (2013) [33] | Assess impact of Assets-Getting to Outcomes intervention on individual prevention practitioners and whole prevention programs in 12 Maine communities | Mixed | Program (program and coalition) | Post |
Baker et al. (2014) [34] | Investigate mental health care workers’ views of a physical health self-management program in South Australia | Qualitative | Provider | Post |
Balas et al. (2013) [35] | Implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting | Mixed | Provider (clinician) | Post |
Cilenti et al. (2012) [11] | Identify factors of successful implementation of evidence-based practices in public health agencies | Qualitative | Department | Post |
Connell et al. (2014a) [18] | Survey therapists’ use of Graded Repetitive Arm Supplementary Program for upper limb stroke rehabilitation in Vancouver, British Columbia | Quantitative | Provider (therapists) | Post |
Connell et al. (2014b) [36] | Implementation of Graded Repetitive Arm Supplementary Program for upper limb stroke rehabilitation in Vancouver, British Columbia | Qualitative | Provider | Post |
Cragun et al. (2014) [19] | Explore how variation in universal tumor screening procedures for colorectal cancer patients influenced patient follow through with germ-line testing after a positive result | Mixed | Organization | Post |
Damschroder and Lowery (2013) [20] | Identify factors affecting implementation of the MOVE! weight management program in Veterans Affairs medical centers | Mixed | Provider | Post |
Draanen et al. (2013) [37] | Examine effectiveness of Toronto Community Addictions Team on service and substance use in Toronto | Mixed | Provider (individual) | During |
English et al. (2011) [38] | Implementation of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals | Mixed | Organization (hospital) | Post |
English et al. (2013) [22] | Design of a tailored intervention strategy to improve hospital services for children in Kenya | Qualitative | NA (designing intervention for hospitals) | Pre |
Forman et al. (2014) [17] | Understanding experiences of primary care leadership, physicians, and staff during Patient Aligned Care Teams early implementation in Veterans Affairs medical centers | Qualitative | Provider (individual provider/staff) | During |
Gilmer et al. (2013) [39] | Implementation of full service partnerships, supportive housing programs for persons with serious mental illness in California | Mixed | Program | During |
Green et al. (2014) [23] | Examine the adoption and use of buprenorphine for opioid addiction treatment in two not-for-profit health plans | Qualitative | Provider | During |
Ilott et al. (2012) [12] | Testing the CFIR through post hoc analysis of 11 narrative accounts of health care service and practice innovation in England | Qualitative | Organization | Post |
Jones et al. (2015) [40] | Implementation of central line associated bloodstream infections reduction project in an orthopedic and trauma surgical unit in an academic health care system in the southeast region of the United States | Quantitative | Organization (hospital unit) | Post |
Kalkan et al. (2014) [9] | Explore the influences on individual rheumatologist’s decisions on prescribing biological drugs in Sweden | Mixed | Provider | Not specified |
Kilbourne et al. (2013) [21] | Measure success of randomized adaptive implementation trial to improve uptake of a re-engagement program for patients with serious mental illness in Veterans Affairs medical centers | Mixed | Organization and patient | During |
Luck et al. (2014) [16] | Evaluation of Patient Aligned Care Teams toolkit across Veterans Affairs medical centers | Mixed | Organization | Post |
Robins et al. (2013) [10] | Investigated potential facilitators and barriers to applying a blood pressure management strategy in a community setting. | Qualitative | Providers and patient | Pre |
Ruffolo and Capobianco (2012) [13] | Investigate the implementation of a family psychoeducation intervention into routine care throughout an entire state. | Qualitative | Organization | Post |
Sanchez et al. (2014) [41] | Examine medication reconciliation implementation in a large academic medical center and its affiliated Veterans Affairs medical center. | Qualitative | Organization | Post |
Shaw et al. (2013) [42] | Examine engagement of health care providers in the implementation of a fall prevention program. | Mixed | Provider | During |
Shimada et al. (2013) [14] | Explore variations in adoption and outcomes of patient-provider secure messaging in Veterans Affairs medical centers. | Quantitative | Organization | During |
Zulman et al. (2013) [43] | Evaluate the large-scale implementation of an internet mediated walking program delivered by a large US health insurance company. | Mixed | Organization | Post |
Zulman et al. (2014) [15] | Evaluate a healthcare delivery redesign process for high-need, high-cost patients in Veterans Affairs medical centers. | Mixed | Organization | During |
Total n = 26 | NA | Qualitative: 10 Quantitative : 3 Mixed: 13 | Organization: 10 Provider: 10 Program: 2 Department: 1 Provider and patient: 1 Organization and patient: 1 NA: 1 | Pre: 2 Post: 15 During: 8 Not specified: 1 |
Research objective
Setting and unit of analysis
Phase of implementation
Study design and methods
Objective 2: depth of CFIR application
Selection and use of CFIR domains and constructs
Application of the CFIR in the methods
Study design | Application of the CFIR in methods |
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Qualitative: n = 10 | Data collection: 1 (10 %) Data analysis: 7 (70 %) Both: 0 (0 %) Neither: 2 (20 %) |
Quantitative: n = 3 | Data collection: 1 (33.3 %) Data analysis: 0 (0 %) Both: 1 (33.3 %) Neither: 1 (33.3 %) |
Mixed methods: n = 13 | Data collection: 4 (30.8 %) Data analysis: 5 (38.5 %) Both: 3 (23.1 %) Neither: 1 (7.7 %) |
Investigation of outcomes using the CFIR
Objective 3: contribution of the CFIR to implementation research
Is CFIR terminology and language coherent?
Does the CFIR promote comparison of results across contexts and studies over time?
Does the CFIR stimulate new theoretical development?
Discussion
The use and selection of CFIR constructs
How the CFIR was used
Phase of implementation
Investigation of outcomes using CFIR constructs
Contribution of the CFIR to implementation science
Recommendation | Rationale | Notes/explanation |
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Consider how to most meaningfully use the CFIR across different phases of implementation (pre-, during, or post-implementation). | Explicit use and reporting of CFIR constructs at various phases of implementation would allow comparisons across phases. | Meaningful pre-implementation assessment would help to identify barriers to address and facilitators to leverage, which in turn, would inform choice of strategies that will increase likelihood of implementation success. In addition, this information can be used to adapt the intervention to fit local context. Meaningful during or post-implementation studies would continue identification of barriers and facilitators to implementation to: ▪ Inform scale-up efforts ▪ Inform implementation of an innovation in other settings/contexts ▪ Associate CFIR constructs with implementation outcomes (if using mixed-methods or quantitative studies) |
Report how CFIR constructs were selected for assessment. | Help to ensure rigor of implementation studies (i.e., that the most salient implementation-related factors were investigated) and promotes the ability to compare research over time and across contexts. | Researchers using the CFIR should clearly report: (1) justification/rationale for selecting CFIR constructs and (2) the CFIR constructs used in the research study. |
Increase use of CFIR to investigate outcomes. | Investigation of outcomes allows for more robust comparisons across studies to identify which constructs influence outcomes and under what conditions. | Researchers should include measurement of implementation outcomes to assess association of CFIR constructs with implementation outcomes. Within the context of investigating outcomes, researchers should: (1) include implementation outcome measures (such as those mentioned by Proctor et al. [25]), (2) provide clearer linkage of CFIR constructs with outcomes, and (3) provide clearer specification of which CFIR constructs were used to investigate outcomes. |
Integrate the CFIR more holistically into the research process. | Integrating the CFIR into research question development and data collection efforts early-on will strengthen research and applicability of findings. | The CFIR should be used throughout the research process. Researchers can use the CFIR Technical Assistance wiki (www.cfirguide.org) to develop research questions, interview and coding guides, as well as to refine CFIR constructs, definitions, and theoretical developments. |