Primary Implementation Outcomes

The RE-AIM framework delineates steps for reporting on factors important to understanding implementation in different settings, including where the greatest barriers to impact may lie, and in turn the potential public health impact of the tested intervention.²²

Reach seeks to understand the targeted patient population’s uptake of an intervention.¹⁸ This was assessed by comparing all those approached to those who consented to be in the study. Furthermore, patients who agreed to participate were followed electronically through study progression to determine points of significant dropout (see Figure 1 for study stages). Patient enrollment, study progression, and study withdrawal were evaluated to identify the impact of patient demographics and clinic setting (i.e. rural vs. urban, academic vs. community). Lastly structured qualitative interviews with eligible and enrolled participants evaluated barriers to enrollment and study completion.

Adoption refers to the representativeness of enrolled clinics and provider-participants as compared to the clinical setting and provider population the intervention was intended to target.¹⁸ All providers at enrolled clinics in each site were compared to those who consented and were enrolled in the study based on demographics. Providers were not rewarded for participation in the study other than benefits gained to quality of their care therefore enrollment is a reasonable measure of adoption. Results from ORIC and qualitative interviews were used to characterize variation in adoption levels by site.

Implementation refers to how adherent sites were to the implementation plan and what variations each introduced to maximize impact at their site.¹⁸ Adaptations were documented through regular teleconferences with the site research staff with ongoing review of enrollment uptake and barriers encountered.

Maintenance measures the “extent to which innovations become a relatively stable, enduring part of the behavioral repertoire of an individual, organization, or community.”¹⁸ In this paper, maintenance was operationalized as monitoring for new clinic accrual and ongoing discussions with health care administrators at the sites about how to make the intervention sustainable in their local contexts. We also assessed acceptability and desire for intervention continuation from patients in a 3-month post-MeTree survey. Patient-level maintenance as measured by behavioral outcomes will be the subject of a later paper.