Table 2 Suggestions for using the AACTT and Proctor Frameworks for specifying de-implementation
Original definitions | Our suggestions/ notes | Illustrative examples from included studies (some quotations have been shortened) |
|---|---|---|
AACTT Framework | ||
Action A discrete observable behaviour | Specify actions, often identified in relation to the outcomes | "reduce excessive medication dosing for patients with clinically important renal impairment." [22] (Pg. 624, Introduction) |
Actor The individual or group of individuals who perform (or should/could) the Action | Specify specific terms to describe exactly who has to change their behaviour (job role, responsibility, the level of actor (team or individual) | "hospital staff at each intervention site (in total 90 nurses, 11 medical officers and 29 clinical officers providing paediatric care" [23] (Pg. 3, The intervention) |
Context The physical, emotional or social setting in which the Actor performs (or should/could) the Action | Specify the clinical setting, location and capacity, the country. Consider ‘context’ frameworks to identify relevant areas of context to ensure key areas of influence such as Culture are considered. | "2 tertiary-care academic hospitals in St John’s, Newfoundland, Canada. The Health Sciences Center (346 acute care beds) provides medicine, pediatric and surgery inpatient services, critical care, cardiac surgery, neurosurgery, plastic surgery, burn treatment, obstetrics/gynecology, and acute psychiatry…The metropolitan area of St John’s has a population of 219,000 people (2017)" [24] (pg. 815, Participants). |
Target The individual or group of individuals for/with/on behalf of whom the Actor performs the Action | Specify the characteristics of the patients | "adult patients (i.e., patients aged 18 years and older) with renal insufficiency who were being discharged home from the ED" [22] (pg. 624, Materials and Methods) |
Time The time period and duration that the Actor performs the Action in the Context with/for the Target | Specify when the action takes place, this could be in relation to a patient (e.g. at the time of admission) or related to the professional (e.g. end of the day) | "Decision support was provided only when a physician in the intervention group attempted to prescribe a targeted inappropriate medication for a patient aged 65 and older who was being discharged from the ED" [25] (Pg. 1389, Methods) |
Proctor Framework | ||
Name it Name the strategy, preferably using language that is consistent with existing literature. | Specify formal descriptive names using established taxonomies | "a validated clinical prediction model (Feverkidstool) was implemented as a decision rule guiding antibiotic prescription" [26] (Pg. 6, Intervention) |
Define it Define the implementation strategy and any discrete components operationally | Specify a detailed description of the intervention, use relevant classification taxonomies | The course on geriatric pharmacology was structured in three main areas…The access to and utilization of each teaching module was linked to a self evaluation test and to specific centralized controls. Each module was divided in four sub-modules that each participant completed with specific case reports and questions [27] (Pg. 55, Intervention) (classified to EPOC taxonomy as Interventions targeted at healthcare workers: Educational materials) |
The actor Identify who enacts the strategy (e.g., administrators, payers, providers, patients/consumers, advocates, etc.). | Specify who provides or delivers the strategy, including job role, relationship to those using the strategy n.b., the actor for a computer decision support strategy can be specified as the computer and the people who programmed it | "An expert panel of two doctors of pharmacy, two physician information technology experts, three geriatricians, and three emergency physicians participated in the design of the intervention" [25] (pg. 1389, Methods) "computerized clinical decision support system" [28] (Pg. 1, Abstract) |
The action Use active verb statements to specify the specific actions, steps, or processes that need to be enacted. | Specify the requirements to set up or deliver the strategy | "Incentive amounts were calculated and communicated quarterly during routine facility visits. . . After communication of the incentive amount earned, facilities submitted a budget to use their incentive allocation and the study team executed the budget…Every effort was made to disburse incentive funds within 4 weeks." [29] (Pg. 4, Incentive intervention) |
Action target (1) Specify targets according to conceptual models of Implementation | Our analysis divided this into 2 distinct targets: (1)Specify the level the strategy participants (& their characteristics) | "All physicians in the participating wards" [27] (Pg. 54, Intervention) [individual] |
(2) Conceptual targets | "We based our intervention on the [PRECEDE] model of behavior change. This model emphasizes the inclusion of predisposing strategies (i.e., increasing provider knowledge about acute respiratory tract infection management), reinforcing strategies (i.e., delivering feedback to providers on past patterns of antibiotic prescribing), and enabling strategies (patient education to reduce antibiotic demand)." [30] (Pg. 223, Interventions) | |
(2) Identify unit of analysis for measuring implementation outcomes | Specify the unit of analysis (and the level of analysis) | "proportion of visits for upper respiratory tract infection and acute bronchitis at which an antibiotic was prescribed" [30] (Pg. 224, Primary Data Analysis) [Patient visit level] |
Temporality Specify when the strategy is used | Specify the timing and length of interaction with a strategy | "Reminders were automatically generated and presented on screen when clinicians entered new information or accessed a patient’s EHR." [28] (pg. 3, CDSS and EHR Integration)[Point of care] |
Dose Specify dosage of implementation strategy | Specify how much of the strategy is experienced at each interaction | "Incentive amounts were calculated and communicated quarterly during routine facility visits." [29] (Pg. 4, Incentive intervention) |
Implementation outcome affected Identify and measure the implementation outcome(s) likely to be affected by each strategy | Specify any outcomes, regardless if it is a implementation outcome | Not an implementation outcome: "We then assessed the effect of TREAT on the management of inpatients in these sites in a cluster randomized controlled trial." [31] (Pg. 1239, Introduction) |
Justification Provide empirical, theoretical, or pragmatic justification for the choice of implementation strategies | Specify the theories, models or frameworks that underpin the strategy. It may be helpful to identify theoretical and empirical evidence. | "Considerable evidence from economic theory and research in other clinical areas suggests that adding a package of feedback, nudges, and peer comparisons could dramatically improve prescribing outcomes. Our investigative team previously showed that relatively simple interventions, grounded in behavioral economics and decision science, that leverage accountability and social norms, can reduce unnecessary antibiotic prescribing for acute respiratory infection (ARI) in primary care practices." [32] (Pg. 720, Introduction) |
Additional construct identified in this study | ||
Interactions | Specify the content/tasks of the strategy that those interacting with the strategy should expect AND how they are expected to interact with the strategy | "Every clinician had to finish his/her e-learning program within 1 month from the start of the study in his/her ward." [27] (Pg. 54, Intervention) "Physicians were asked to inspect TREAT’s result interface, but the final choice of antibiotic treatment was theirs." [24] (Pg. 1240, Methods) |