Implementation of a stepped wedge cluster randomized trial to evaluate a hospital mobility program

Abstract

Background: Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs.

Methods: Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals.

Results: Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks (4 hospitals per block) to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6-8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE (for example, using existing staff to conduct walks until new positions were filled).

Conclusions: Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a "ramp-up" period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.

Trial registration: ClinicalsTrials.gov NCT03300336 . Prospectively registered on 3 October 2017.

Keywords: Mobility; Pragmatic trials; Stepped wedge.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Originally proposed blocked SW-CRT design for Function QUERI STRIDE. “0” indicates pre-implementation period, “.” indicates implementation period (STRIDE launch), “1” indicates post-implementation period, and “0” in shaded gray indicates prior to VA hospital recruitment for block 2 where primary outcome data for control time periods can still be collected via EHR (but not patient-reported data in these blocks because the sites have not enrolled in the study during this time period)

Fig. 2

Function QUERI STRIDE SW-CRT site recruitment and enrollment

Fig. 3

Implemented blocked SW-CRT design for Function QUERI STRIDE with 6-month delay in recruitment of block 2 sites. “0” indicates pre-implementation period, “.” indicates implementation period (STRIDE launch), “1” indicates post-implementation period, and “0” in shaded gray indicates prior to VA hospital recruitment for block 2 where primary outcome data for control time periods can still be collected via EHR (but not patient-reported data in these blocks because the sites have not enrolled in the study during this time period)