KT Intervention to Increase Use of Outcome Measures
Condition: Knowledge Translation
Study type: Interventional

Summary: 
      Knowledge brokers can facilitate knowledge translation (KT) interventions to improve the use
      of outcome measures by physical therapists. Following the Knowledge-to-Action cycle, a
      knowledge broker (a researcher who facilitates the translation of knowledge in the local
      context) will: (1) complete a barrier assessment, (2) develop and implement a tailored
      multi-modal intervention and (3) determine the outcome. The KB will determine the barriers
      and facilitators to using outcome measures by PTs who work in inpatient rehabilitation and
      design a locally tailored KT intervention with input from the key stakeholders (PTs). This
      cluster randomized trial will compare two active interventions with full or partial supported
      implementation by a knowledge broker using a cluster randomized trial (randomization will
      occur by site) to determine the impact on the PTs and patients.

      Aim 1: Determine if the KT intervention designed and implemented by a KB will increase PTs
      the use of a selected standardized assessment as compared to an intervention that is designed
      but not implemented by the KB.

      Hypothesis1a: Physical therapists use (documented and self-reported) of a selected
      standardized assessment will improve to a significantly greater extent immediately following
      the intervention designed and implemented by a KB compared to the partially supported group.

      Hypothesis1b: Physical therapists in the fully supported group will retain the use of the
      standardized assessment to a significantly greater extent at 6 month follow-up.

      Aim 2: Explore and compare both groups of physical therapists satisfaction and concerns with
      each KT intervention on standardized assessment use.

      Hypothesis 2: The physical therapists in the fully supported group will express greater
      satisfaction with the KT intervention and identify fewer barriers for implementing the
      standardized assessment in practice as compared to the partially supported group immediately
      after and retained at 6 month follow-up.

      Aim 3: Explore and compare the patients' experience who were seen by therapists in the fully
      and partially supported group Hypothesis 3: Patients who were treated by clinicians in the
      fully supported group will demonstrate an understanding of the patient standardized
      assessment, why it's relevant to complete the test, and how the information gathered from the
      standardized assessment can be used to guide the plan of care.
    

Detailed description: 
      Purpose/Specific Aims

        1. Design two locally tailored multi-modal knowledge translation interventions using a
           mixed methods barrier assessment with input from the clinicians.

        2. Compare the effectiveness of the interventions on physical therapists' use of
           standardized assessments/outcome measures.

             -  The fully supported group will have the intervention designed and implemented by
                the investigator (knowledge broker)

             -  The partially supported group will have the intervention designed and only partial
                implementation by the investigator (knowledge broker)

        3. Determine the impact of the intervention on patients who were evaluated by PTs in both
           groups.

      Objectives

        1. To determine the immediate and longer term (6 months following the intervention)
           effectiveness of a theoretically informed multi-modal tailored intervention designed and
           implemented by a knowledge broker as compared to a tailored intervention designed, but
           only partially implemented by the knowledge broker on the use of a selected patient
           standardized assessment by physical therapists who work in rehabilitation.

        2. To explore and compare patients' experiences of being evaluated by PTs in the fully
           supported and partially supported groups.

           The proposed study intends to compare two KT interventions designed by a KB using an
           fully supported and partially supported implementation groups. The outcomes will be
           measured through mixed methods to determine the immediate and 6 month retention of
           behavior change, impact of the intervention, and investigate the impact of the
           intervention on patients. Quantitative data analysis will be used through chart audit to
           determine documentation of outcome measures and a self-reported survey (Goal Attainment
           Scale). Qualitative analysis (focus groups) will be used to determine reasons for
           behavior change which can be used to guide future interventions. Long term analysis also
           helps investigators determine if the behavior was retained after the intervention was
           completed. Finally, few studies have investigated the impact of the intervention on the
           patients and an exploratory focus group will compare patients treated by physical
           therapists in the experimental and control groups.

        3. Research Design and Methods This is a mixed methods cluster randomized controlled trial
           with 2 sites. Phase I: Barrier Assessment and Intervention Design The interventions will
           be designed by the knowledge broker with input from the clinicians through a barrier
           assessment. The barrier assessment will include a chart audit, a questionnaire and a
           focus group. The chart audit will be used to determine current use of standardized
           assessments. The questionnaire will be used assess current use, barriers, and
           facilitators to evidence based practice and using standardized assessments. The
           clinicians will be given a link to access and complete the barrier assessment survey
           anonymously. The barriers and facilitators to evidence based practice (EBP) and using
           outcome measures questionnaire was developed and validated in a previous study and
           designed using the Theoretical Domains Framework (TDF). The questionnaire contains a
           question on which outcome measure the participants would like to use more frequently, to
           help guide selection of the standardized assessment. The focus group will present chart
           audit and questionnaire data, confirm barriers and facilitators, and determine the
           strategies that will be used in the intervention based on the Theoretical Domains
           Framework consensus matrix.

      Standardized assessments will be selected by the groups through the following process:
      Participants will complete a question on the questionnaire about which standardized
      assessments they would like to use more frequently. Those results will be tallied and two
      standardized assessment will be briefly presented to the experimental and active control
      groups during the first focus group. The two standardized assessments presented must be
      performance based, comprise of only a few steps, be easy to interpret and have at least
      adequate psychometric properties (reliability and validity testing) Each group will select a
      comparable outcome measure/standardized assessment based on the two standardized assessment
      the investigators selects to present. The group will be asked to select one assessment based
      on group consensus of 80%. Disagreement will be handled through discussion. Each group can
      choose different standardized assessments.

      Phase II: Intervention The trial will be conducted in two inpatient rehabilitation hospitals
      within the same organization, Kessler (Chester and Saddle Brook locations). The fully
      supported group (enhanced arm) will receive a theoretically informed tailored multi-modal
      intervention designed and implemented by a knowledge broker (investigator) to increase the
      use of a selected standardized assessment. A knowledge broker (KB) is a researcher who brings
      evidence to the clinicians with the purpose to change practice. KBs are able to locally
      tailor interventions for the clinicians. The partially supported arm will also receive a
      theoretically informed tailored multimodal intervention that will be designed, and only
      partially implemented by the KB. The groups will be randomization, by site, after the barrier
      assessment is completed (Chester or Saddle Brook). Randomization by site was selected to
      reduce contamination among the therapists.

      The fully supported group will have 2 additional meetings with the Knowledge Broker (KB) to
      assist with implementation and barrier assessment. The KB will meet with the fully supported
      group six times to design and implement the intervention, and the KB will meet with the
      partially supported group four times to design and partially implement the intervention. The
      KB will encourage both groups to use the selected standardized assessment. The fully
      supported group will have four educational outreach visits over a four month period. Two of
      the four outreach visits will occur simultaneously with focus groups and provide feedback
      from chart audit data on current use of the selected standardized assessment and design the
      intervention by discussing an action plan to determine strategies to increase the use of the
      selected assessment. The investigator will implement the intervention in the two additional
      outreach visits. Strategies will be tailored to the group and may include: distribution of
      educational materials, an interactive educational meeting, and reminders. The partially
      supported arm will have two educational outreach visits where the intervention/action plan
      will be designed but not implemented by the investigator. The partially supported arm will be
      encouraged to self-implement the intervention during months 2 and 4.

      Phase III: Outcome Assessment Outcomes will be assessed to determine documented and
      self-reported use of the selected standardized assessment through chart audit at baseline,
      immediately post intervention and 6 month follow-up. Focus groups will be conducted at post
      intervention and follow-up to explore and compare the impact of the intervention on behavior
      change, facilitators to change and barriers that remained among each group. In addition, four
      focus groups will be held with patients of the therapists' in each group to explore and
      compare their experience.

      3.3 Sample Size Justification Physical Therapist- up to 40 PTs, 20 at each location will be
      invited to participate. The sample size is based on the number of PTs who work at Kessler and
      a power calculation based on pilot research.

      Patients treated by the enrolled PTs- up to 24; 3-6 in each group.

      3.3.1 Power Calculation: A power calculation was completed using the pilot study data. Based
      on the pilot study data, two groups of 6 will achieve an effect size of .7 and power of 81%.

      Baseline data:

      Group equivalency at baseline will be analyzed using the following variables: age, gender,
      years of experience, and educational level will be analyzed using either an unpaired t-test
      or Mann-Whitney U test. Continuous data (age, years of experience, use of standardized
      assessments) will be analyzed using an unpaired t-test if assumptions of normality are met
      and Levene's test of homogeneity is not significant. Level of significance will be set at .1.
      A Mann-Whitney U test will be used for ordinal data and data that are not normal. Variables
      on which the groups differ at baseline will be considered for inclusion in the final models
      as covariates.

      Barrier assessment questionnaire data will be analyzed descriptively to guide intervention
      development. The baseline focus group will be transcribed, coded and themes will be created.

      Documented use of the standardized assessment will be analyzed using a within-between,
      repeated measures ANOVA, with time and group as factors. If data are non-normal attempts will
      be made to transform the dependent variables to meet parametric standards. Another option
      will be to explore statistical procedures that model non-Gaussian distributions. Level of
      significance will be set at .05.

      Self-reported use will be analyzed using the Goal Attainment Scale using the Friedman's test
      because data are ordinal. The Friedman's test will used for within group analysis only.
      Comparisons between groups will be reported descriptively or alternatively, a
      post-intervention Mann-Whitney U may be used. Level of significance will be set at .05.

      Focus group: Each focus group will be recorded and transcribed and conventional content
      analysis will be conducted. After the focus group is transcribed, open coding will occur by
      coding notes, observations, and comments in the margins of potentially relevant information.
      Similar notes, observations and comments will be grouped together into categories or themes.
      Appropriate categories will be associated with Theoretical Domains Framework and the
      Consolidated Framework for Implementation Research (CFIR) into codes and rated. Experiences
      will be determined by satisfaction with the intervention, perceived facilitators for changing
      their behavior and barriers that remain. Several steps will be taken to establish
      trustworthiness of the qualitative data..

      Realist Analysis: Chart audit data will be used as the Outcome and Qualitative codes from the
      CFIR will be entered as Mechanisms (Interventions) or Context. Codes and ratings will be
      compared with chart audit data to determine reasons for use or non-use.

      Patient Focus group: The patient focus group, will be used to compare the experiences of
      patients treated by therapists in the intervention and control groups. Each focus group will
      be recorded and transcribed. Open coding will occur as I will write notes, observations, and
      comments in the margins of potentially relevant information of the transcribed focus group.
      Similar notes, observations and comments will be grouped together into categories or themes.
      Categories will be compared across groups.
    

Intervention name(s): Knowledge Broker
Intervention type(s): Behavioral
Intervention description(s): Tailored knowledge translation intervention that included barrier assessment and intervention mapping using the theoretical domains framework and participant engagement either fully or partially supported by the knowledge broker.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 2 groups cluster randomized controlled trial
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: physical therapy; knowledge translation; outcome measures; knowledge brokering