Bridging the evidence-to-practice gap: a stepped-wedge cluster randomized controlled trial evaluating practice facilitation as a strategy to accelerate translation of a multi-level adherence intervention into safety net practices

Antoinette Schoenthaler, Franzenith De La Calle, Amanda Soto, Derrel Barrett, Jocelyn Cruz, Leydi Payano, Marina Rosado, Samrachana Adhikari, Gbenga Ogedegbe, Milagros Rosal, Antoinette Schoenthaler, Franzenith De La Calle, Amanda Soto, Derrel Barrett, Jocelyn Cruz, Leydi Payano, Marina Rosado, Samrachana Adhikari, Gbenga Ogedegbe, Milagros Rosal

Abstract

Background: Poor adherence to antihypertensive medications is a significant contributor to the racial gap in rates of blood pressure (BP) control among Latino adults, as compared to Black and White adults. While multi-level interventions (e.g., those aiming to influence practice, providers, and patients) have been efficacious in improving medication adherence in underserved patients with uncontrolled hypertension, the translation of these interventions into routine practice within "real world" safety-net primary care settings has been inadequate and slow. This study will fill this evidence-to-practice gap by evaluating the effectiveness of practice facilitation (PF) as a practical and tailored strategy for implementing Advancing Medication Adherence for Latinos with Hypertension through a Team-based Care Approach (ALTA), a multi-level approach to improving medication adherence and BP control in 10 safety-net practices in New York that serve Latino patients.

Methods and design: We will conduct this study in two phases: (1) a pre-implementation phase where we will refine the PF strategy, informed by the Consolidated Framework for Implementation Research, to facilitate the implementation of ALTA into routine care at the practices; and (2) an implementation phase during which we will evaluate, in a stepped-wedge cluster randomized controlled trial, the effect of the PF strategy on ALTA implementation fidelity (primary outcome), as well as on clinical outcomes (secondary outcomes) at 12 months. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions outlined by Proctor's Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as BP< 130/80 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records).

Discussion: The study protocol applies rigorous research methods to identify how implementation strategies such as PF may work to expedite the translation process for implementing evidence-based approaches into routine care at safety-net practices to improve health outcomes in Latino patients with hypertension, who suffer disproportionately from poor BP control. By examining the barriers and facilitators that affect implementation, this study will contribute knowledge that will increase the generalizability of its findings to other safety-net practices and guide effective scale-up across primary care practices nationally.

Trial registration: ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.

Keywords: Hypertension; Latino persons; Medication adherence; Practice facilitation; Primary care.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Stepped-wedge design of ALTA implementation
Fig. 2
Fig. 2
ALTA conceptual model
Fig. 3
Fig. 3
Excerpt of structured tool to assess implementation fidelity

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