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In Search of Synergy: Multilevel Implementation Interventions - - PowerPoint PPT Presentation
In Search of Synergy: Multilevel Implementation Interventions - - PowerPoint PPT Presentation
In Search of Synergy: Multilevel Implementation Interventions Bryan J. Weiner, Ph.D. You think because you understand 'one' you must also understand 'two', because one and one make two. But you must also understand 'and'. ~ Rumi GOT
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GOT SYNERGY?
- Implementation facilitators and barriers operate at
multiple levels of influence
- Yet, multi-level implementation interventions often don’t
work better than single-level ones Why?
- Selected implementation interventions do not target key
determinants of the problem
- Interdependence of key determinants of the problem are
poorly understood
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THE CAUSAL LOGIC OF MULTILEVEL INTERVENTION
We explored how interventions at different levels could be combined to produce complementary or synergistic effects …using a causal modeling framework to develop potential combinations We concentrated on two forms
- f causal interdependence:
mediation and moderation …and identified 5 potentially useful strategies for combining interventions at different levels
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MEDIATION Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable.
5
IV M DV
Full Mediation
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MEDIATION Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable
IV M DV
Partial Mediation
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MEDIATION Mediator: a variable that explains (or accounts for) the relationship between the dependent variable and the independent variable
IV M DV
Parallel Mediation
M
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MEDIATION
8
IV M DV
Serial Mediation
M
Mediator: A variable that explains (or accounts for) the relationship between the dependent variable and the independent variable.
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MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables.
IV W DV
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MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables.
IV W DV W
Multiple Moderation
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MODERATION Moderator: A variable that changes the strength of an effect or relationship between two variables.
IV W DV W
Moderated moderation
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COMBINATIONS Moderated mediation: Mediating process or pathway is intensified or attenuated by individual difference or contextual condition.
IV M DV W W
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SOCIAL ECOLOGICAL MODEL Levels as Settings*
* Or social units
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SOCIAL ECOLOGICAL MODEL Levels as Determinants
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Example: Possible Barriers to or Determinants of Colorectal Cancer Screening
Level of Influence Possible Barrier/Determinant Intervention Strategy
Intrapersonal
- Patient/provider knowledge, attitudes, beliefs
- Patient structural barriers (e.g., time, money)
- Inadequate cues to action
- Education, training, navigation
- Decision support
- Reminders
Interpersonal
- Poor physician-patient communication
- Inadequate social/spousal support
- Professional (social) norms about screening
- Communication
- Shared decision making
- Social support
- Opinion leaders
Organizational
- Poor care coordination, inefficient processes
- Inadequate staffing, inadequate data systems
- Quality improvement
- Service/staffing changes
- Role revisions, registries
Community
- Low community awareness/demand
- Inadequate supply of diagnostic colonoscopy
services
- Social marketing campaign
- Assisted transportation services
Macro Policy
- Limited or lack of insurance coverage
- Inadequate incentives to coordinate care
- Insurance coverage changes
- Bundled payment policies
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- 1. ACCUMULATION STRATEGY
Legend Box: intervention and level of influence (in parentheses) Diamond: mediator Oval: outcome
Public reporting* (organizational) Op Opinion Leader (I (Interpersonal) Outreach visit (Intrapersonal)) Physician’s motivation Colorectal Cancer Screening *For expositional purposes, the diagram depicts interventions rather than determinants as causes. To keep the concept simple, a single mediating pathway is presented.
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- 2. AMPLIFICATION STRATEGY
Public reporting* (Organizational) Opinion leader (Interpersonal) Audit and feedback (Intrapersonal) Physician’s motivation Colorectal Cancer Screening
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- 3. FACILITATION STRATEGY
Public reporting* (Organizational) Opinion leader (Interpersonal) Clinical reminder (Intrapersonal) Physician’s motivation Colorectal Cancer Screening
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- 4. CASCADE STRATEGY
Office systems
Colorectal Cancer Screening
Quality improvement (Organizational) Physician motivation Outreach visit (Intrapersonal) Manager motivation Advocacy at state level (Macro Policy)
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- 5. CONVERGENCE STRATEGY
Public reporting* (Organizational) Opinion leader (Interpersonal) Patient education (Intrapersonal) Physician motivation Colorectal Cancer Screening Patient motivation Provider- patient interaction
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AMPLIFICATION STRATEGY
Clinician’s motivation Participation in Training Incentives (Intrapersonal) Social norms Opinion leader (Interpersonal)
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WHAT’S NEEDED
> Multilevel theories that explain how determinants at multiple levels interact to produce health and other
- utcomes