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      Training Intervention and Program of Support for Fostering the Adoption of Family-Centered Telehealth in Pediatric Rehabilitation: Protocol for a Multimethod, Prospective, Hybrid Type 3 Implementation-Effectiveness Study

      , PT, PhD 1 , 2 , 3 , , , PhD 2 , , BSc 4 , , PhD 5 , , PhD 6 , , PhD 1 , 3 , , MD 3 , 7 , , MD 3 , 7 , , PhD 8 , , PhD 9 , , PhD 3 , 10 , 11 , , PhD 12 , 13 , , PhD 4 , 13 , , PhD 14 , 15 , , PhD 16 , 17 , , PhD 16 , 17 , , PhD 3 , 18 , , PhD 13 , , PhD 19 , , PhD 11 , 20 , , MBA 21 , , MScN 22 , , MPT 23 , , BM, BME 23 , , PhD 3 , 4 , 13
      JMIR Research Protocols
      JMIR Publications
      telehealth, pediatric rehabilitation, training, therapists, pediatrics, physical therapy, health care, family-centered care

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          Children with disability face long wait times for rehabilitation services. Before the COVID-19 pandemic, telehealth adoption was low across pediatric rehabilitation. Owing to the COVID-19 pandemic restrictions, pediatric therapists were asked to rapidly shift to telehealth, often with minimal training. To facilitate the behavior changes necessary for telehealth adoption, provision of appropriate evidence-based training and support is required. However, evidence to support the effective implementation of such training is lacking. The successful real-world implementation of a training intervention and program of support (TIPS) targeting pediatric therapists to enhance the adoption of family-centered telerehabilitation (FCT) requires the evaluation of both implementation and effectiveness.


          This study aimed to evaluate TIPS implementation in different pediatric rehabilitation settings and assess TIPS effectiveness, as it relates to therapists’ adoption, service wait times, families’ perception of service quality, and costs.


          This 4-year, pan-Canadian study involves managers, pediatric occupational therapists, physiotherapists, speech-language pathologists, and families from 20 sites in 8 provincial jurisdictions. It will use a multimethod, prospective, hybrid type 3 implementation-effectiveness design. An interrupted time series will assess TIPS implementation. TIPS will comprise a 1-month training intervention with self-paced learning modules and a webinar, followed by an 11-month support program, including monthly site meetings and access to a virtual community of practice. Longitudinal mixed modeling will be used to analyze indicators of therapists’ adoption of and fidelity to FCT collected at 10 time points. To identify barriers and facilitators to adoption and fidelity, qualitative data will be collected during implementation and analyzed using a deductive-inductive thematic approach. To evaluate effectiveness, a quasi-experimental pretest-posttest design will use questionnaires to evaluate TIPS effectiveness at service, therapist, and family levels. Generalized linear mixed effects models will be used in data analysis. Manager, therapist, and family interviews will be conducted after implementation and analyzed using reflective thematic analysis. Finally, cost data will be gathered to calculate public system and societal costs.


          Ethics approval has been obtained from 2 jurisdictions (February 2022 and July 2022); approval is pending in the others. In total, 20 sites have been recruited, and data collection is anticipated to start in September 2022 and is projected to be completed by September 2024. Data analysis will occur concurrently with data collection, with results disseminated throughout the study period.


          This study will generate knowledge about the effectiveness of TIPS targeting pediatric therapists to enhance FCT adoption in pediatric rehabilitation settings, identify facilitators for and barriers to adoption, and document the impact of telehealth adoption on therapists, services, and families. The study knowledge gained will refine the training intervention, enhance intervention uptake, and support the integration of telehealth as a consistent pediatric rehabilitation service option for families of children with disabilities.

          Trial Registration

          ClinicalTrials.gov NCT05312827; https://clinicaltrials.gov/ct2/show/NCT05312827

          International Registered Report Identifier (IRRID)


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          Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

          Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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            Interrupted time series regression for the evaluation of public health interventions: a tutorial

            Abstract Interrupted time series (ITS) analysis is a valuable study design for evaluating the effectiveness of population-level health interventions that have been implemented at a clearly defined point in time. It is increasingly being used to evaluate the effectiveness of interventions ranging from clinical therapy to national public health legislation. Whereas the design shares many properties of regression-based approaches in other epidemiological studies, there are a range of unique features of time series data that require additional methodological considerations. In this tutorial we use a worked example to demonstrate a robust approach to ITS analysis using segmented regression. We begin by describing the design and considering when ITS is an appropriate design choice. We then discuss the essential, yet often omitted, step of proposing the impact model a priori. Subsequently, we demonstrate the approach to statistical analysis including the main segmented regression model. Finally we describe the main methodological issues associated with ITS analysis: over-dispersion of time series data, autocorrelation, adjusting for seasonal trends and controlling for time-varying confounders, and we also outline some of the more complex design adaptations that can be used to strengthen the basic ITS design.
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              Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact.

              This study proposes methods for blending design components of clinical effectiveness and implementation research. Such blending can provide benefits over pursuing these lines of research independently; for example, more rapid translational gains, more effective implementation strategies, and more useful information for decision makers. This study proposes a "hybrid effectiveness-implementation" typology, describes a rationale for their use, outlines the design decisions that must be faced, and provides several real-world examples. An effectiveness-implementation hybrid design is one that takes a dual focus a priori in assessing clinical effectiveness and implementation. We propose 3 hybrid types: (1) testing effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation; (2) dual testing of clinical and implementation interventions/strategies; and (3) testing of an implementation strategy while observing and gathering information on the clinical intervention's impact on relevant outcomes. The hybrid typology proposed herein must be considered a construct still in evolution. Although traditional clinical effectiveness and implementation trials are likely to remain the most common approach to moving a clinical intervention through from efficacy research to public health impact, judicious use of the proposed hybrid designs could speed the translation of research findings into routine practice.

                Author and article information

                JMIR Res Protoc
                JMIR Res Protoc
                JMIR Research Protocols
                JMIR Publications (Toronto, Canada )
                October 2022
                28 October 2022
                : 11
                : 10
                : e40218
                [1 ] School of Rehabilitation Sciences Faculty of Health Sciences McMaster Univeristy Hamilton, ON Canada
                [2 ] Department of Family Medicine and Emergency Medicine Faculty of Medicine and Health Sciences Université de Sherbrooke Longueuil, QC Canada
                [3 ] CanChild Centre for Childhood Disability Research School of Rehabilitation Sciences McMaster University Hamilton, ON Canada
                [4 ] Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke Sherbrooke, QC Canada
                [5 ] Department of Medicine Faculty of Medicine and Health Sciences Université de Sherbrooke Sherbrooke, QC Canada
                [6 ] Department of Family Medicine McGill Univeristy Montreal, QC Canada
                [7 ] Department of Pediatrics McMaster University Hamilton, ON Canada
                [8 ] School of Rehabilitation Sciences University of Saskatchewan Saskatoon, SK Canada
                [9 ] Department of Physical Therapy University of Alberta Edmonton, AB Canada
                [10 ] Department of Occupational Sciences and Occupational Therapy University of British Columbia Vancouver, BC Canada
                [11 ] BC Children's Hospital Research Institute Vancouver, BC Canada
                [12 ] Institut Universitaire de Première Ligne en Santé et Services Sociaux Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke Sherbrooke, QC Canada
                [13 ] École de Réadaptation Faculté de Médecine et Sciences de la Santé Univeristé de Sherbrooke Sherbrooke, QC Canada
                [14 ] School of Public Health Université de Montréal Montréal, QC Canada
                [15 ] Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est de l'Île de Montréal Montréal, QC Canada
                [16 ] Population Health and Optimal Health Practices Research Unit, Centre Hospitalier de Québec-Univeristé Laval Research Centre Québec, QC Canada
                [17 ] Faculty of Nursing Univeristé Laval Québec, QC Canada
                [18 ] Faculty of Medicine Univeristé de Montréal Montréal, QC Canada
                [19 ] Occupational Science and Occupational Therapy Department University of Toronto Toronto, ON Canada
                [20 ] Department of Physical Therapy Univeristy of British Columbia Vancouver, BC Canada
                [21 ] Empowered Kids Ontario East York, ON Canada
                [22 ] Children's Healthcare Canada Ottawa, ON Canada
                [23 ] Training Intervention and Program of Support Study Team Université de Sherbrooke Sherbrooke, QC Canada
                Author notes
                Corresponding Author: Karen Hurtubise hurtubik@ 123456mcmaster.ca
                Author information
                ©Karen Hurtubise, Isabelle Gaboury, Jade Berbari, Marie-Claude Battista, Tibor Schuster, Michelle Phoenix, Peter Rosenbaum, Olaf Kraus De Camargo, Stacey Lovo, Lesley Pritchard-Wiart, Jill G Zwicker, Audrée Jeanne Beaudoin, Mélanie Morin, Thomas Poder, Marie-Pierre Gagnon, Geneviève Roch, Danielle Levac, Michel Tousignant, Heather Colquhoun, Kimberly Miller, Jennifer Churchill, Paula Robeson, Andréa Ruegg, Martine Nault, Chantal Camden. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 28.10.2022.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.

                : 9 July 2022
                : 21 July 2022
                : 28 July 2022
                : 4 August 2022
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                This paper was peer reviewed by the Canadian Institutes of Health Research (CHIR)/Instituts de recherche en santé du Canada (IRSC) - Institut des services et des politiques de la santé / Institute of Health Services and Policy Research - Knowledge Translation Research/Recherche sur l'application des connaissances (Canada). See the Multimedia Appendix for the peer-review report;

                telehealth,pediatric rehabilitation,training,therapists,pediatrics,physical therapy,health care,family-centered care


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