Adapting community based participatory research (CBPR) methods to the implementation of an asthma shared decision making intervention in ambulatory practices

Figures & data

Table 1. Description of study practices.

	Total number	Number of internally	Number of targeted	Asthma patient demographics
Clinic (in roll-out order)	of providers	trained health coaches	asthma patients	Race	Insurance
Clinic 1: Family Medicine	8	1 Pharmacist 2 Nurses	260	African American – 51% Caucasian – 12% Hispanic − 22%	Medicaid – 58% Medicare – 2% Insurance − 8% Self Pay – 30%
Clinic 2: Pediatric Teen Specialty Health	4	1 Patient Educator 1 Pharmacist 1 Care coordinator (RN)	128	African American – 74% Caucasian – 16% Hispanic – 6%	Medicaid – 67% Other Insurance − 14% Self Pay – 19%
Clinic 3: Family Medicine	8	2 Pharmacists	226	African American – 83% Caucasian – 11% Hispanic − 3%	Medicaid – 55% Medicare – 4% Other Insurance −11% Self Pay − 30%
Clinic 4: Family Medicine	40^a	1 Care coordinator (RN) 1 Pharmacist 1 Physician assistant	248	African American – 70% Caucasian – 22% Other − 8%	Medicaid – 56% Medicare – 10% Other Insurance −18% Self Pay −16%
Clinic 5: Pediatrics	40^a	1 Pharmacist	643	African American − 60% Caucasian – 11% Hispanic − 26%	Medicaid – 87% Other Insurance − 5% Self Pay − 8%
Clinic 6: Internal Medicine	48^a	1 Educator 1 Pharmacist 2 Nurses	561	African American − 75% Caucasian – 17% Hispanic − 3%	Medicaid – 21% Medicare – 33% Other Insurance − 10% Self Pay − 36%

^aResidency training practices.

Figure 1. Examples of shared decision making materials adapted to accommodate Spanish-speaking and pediatric patients.

Figure 2. Roll-out plan used to guide implementation of the shared decision making intervention.

Table 2. RE-AIM analysis of roll-out of shared decision making intervention.

	Reach
Clinic	Whether clinic adopted the intervention (yes/no)	Number (%) of asthma patients with SDM visit, N (%)	Half-day SDM clinics, N	Effectiveness^a patient participation in treatment decision, N (%)	Adoption provider participation in intervention, N (%)	Implementation utilization of intervention components in SDM patient encounters, (%)	Maintenance continuation of delivery of SDM intervention, (%)
1	Yes	36/260 (13.85)	16	32/33 (97.0)	3/8 (37.5)	Office spirometry: offered to 100% of patients ≥ 7 years Medication planner (decision support tool): utilized in 100% of SDM visits	100% of practices intend to continue the intervention after the study ends October 2013 Evaluation of long-term maintenance is premature
2	Yes	17/128 (13.28)	10	11/15 (73.3)	3/4 (75)
3	Yes	32/226 (14.16)	15	39/40 (98.0)	3/8 (37.5)
4	Yes	17/248 (6.85)	11	23/24 (95.8)	9/40^b (22.5)
5	Yes	12/643 (1.87)	10	12/15 (80.0)	4/40^b (10)
6	Yes	11/561 (1.96)	5	10/13 (76.9)	2/48^b (4.2)
Summary	6/6 (100%) of clinics who were offered the intervention	125/2066 (6.05)	Average = 11.2 half-days	127/140 (90.7)	24/148 (16)

^aProportion of patients surveyed who rated treatment choice as a shared decision between patient and health care provider.

^bResidency training practices.

Table 3. Overview of process evaluation focus group themes.

Major themes	Sub themes
Intervention implementation	(1) Intervention sustainability – ability of the intervention to continue after the research project finished, given clinic resources, and the retention of implementation-trained personnel (2) Productivity – need for providers to maintain practice productivity targets. Providers were concerned that, while the SDM intervention may lead to better outcomes for a few patients, it may take time away from treating a greater volume of patients (3) Tailoring – the need for the intervention to adapt to the culture and patient population of each individual clinic (4) Stakeholder identification – focused on recognition that each clinic operates and utilizes its personnel differently and that the needs and perspectives of different groups and individuals needed to be accommodated (5) Intervention training – an issue that emerged as practices rolled out the intervention and as new staff were recruited. Improvements in the training process were developed based on focus group comments
Participatory process	(1) Inclusion – participants were intentionally included in the roll-out and participatory process. A research-team-initiated feedback process consisting of individual practice updates at each meeting, coupled with an informal and open atmosphere, allowed for an honest and on-going discussion of the implementation process (2) Knowledge exchange –members were able to freely discuss and brainstorm solutions to problems as well as anticipate potential and perceived barriers. Facilitators allowed those involved in implementation to exchange knowledge on what worked while pre-implementation practices still had time to proactively address potential issues (3) Open communication – members not only felt that they were able to voice their opinions and reflect upon their experiences but also felt that their opinions were respected during the process (4) Investment – team members felt that the intervention would help their patients. In particular, they mentioned the patients would benefit from shared decision making and the availability of better resources for asthma care (5) Productivity – meeting structure, frequency, and rotating location allowed action items and productivity targets to be met in a timely manner