Implementation Studies

The Center for Behavioral Cardiovascular Health (CBCH) is committed to bringing research and technology together to implement change in the front lines of patient care.

What is Implementation Science?

The study of methods to promote the integration of research findings and evidence into healthcare policy and routine practice.

What is ImSci Lab?

The Im_Sci lab is a multidisciplinary, health services research group at Columbia University Irving Medical Center dedicated to integrating implementation science, human centered design and behavioral science methods to conduct impact focused, mechanistically driven, dynamic digital health interventions for reducing chronic disease disparities. The Im_Sci lab is dedicated to developing novel implementation science methods, training a new generation of implementation scientists, and conducting impact focused, mechanistically driven, dynamic interventions for reducing cardiovascular disease disparities. Optimizing trial designs in real world settings remains challenging, and our work will contribute to our understanding the theoretical underpinnings needed to design effective trials to maximize intervention fidelity and outcomes.

Our Goal/Mission

Our vision: A world where who you are and where you come from do not determine the quality of care you receive.

Our mission is to use implementation science to bridge the chasm between evidence and practice, particularly in disadvantaged populations.

Our goals are

(1) To involve patients, providers and healthcare systems in the design, implementation, and dissemination of digital behavioral health interventions

(2) To create sustained behavioral change and improvements in chronic health outcomes

(3) To create theory-informed, scalable digital health interventions that target the intersection of mental and cardiovascular health.

Our Projects

1) Embrace

 

Approximately 1 in 3 patients has elevated blood pressure (BP) when measured in the doctor’s office, but normal BP when measured out of the office setting, a phenomenon known as white coat hypertension. Misdiagnosing such patients with hypertension can lead to unnecessary treatment with blood pressure (BP) medications, wasteful healthcare utilization, and adverse psychological consequences due to labeling effects. In 2015, the United Services Preventive Services Task Force (USPSTF) updated their hypertension screening guidelines to recommend that patients with elevated office BP undergo out-of-office BP testing with 24-hour Ambulatory BP Monitoring (ABPM) or Home BP Monitoring (HBPM) to rule-out white-coat hypertension prior to a new diagnosis of hypertension.

Despite the USPSTF recommendation, ABPM and HBPM are infrequently utilized in the US. Accordingly, the investigators conducted focus groups with primary care providers, patients, and other key stakeholders to identify the major barriers to implementation of the new hypertension screening guidelines. The investigators then applied the Behavior Change Wheel, a trans-theoretical intervention development framework, to categorize barriers and select theory-informed intervention components that would address these barriers.

The investigators arrived at a theory-informed implementation strategy comprised of the following 7 components:

  • educational activities for providers
  • training registered nurses to teach patients how to conduct HBPM
  • disseminating information on how to order ABPM and HBPM to clinicians
  • creating a computerized electronic health record-embedded clinical decision support tool that prompts recall of the guideline and facilitates ABPM and HBPM test ordering
  • creating and disseminating patient information materials on ABPM and HBPM
  • providing periodic feedback about clinic-level success with adhering to the guideline
  • developing an easily accessible, culturally-adapted and locally tailored ABPM service

The investigators are now conducting a 2-year cluster randomized trial (https://clinicaltrials.gov/ct2/show/NCT03480217) that tests whether this multifaceted implementation strategy increases the uptake of the USPSTF hypertension recommendations in the Ambulatory Care network (ACN) of New York-Presbyterian Hospital (NYP), a network of primary care clinics serving 120,000 patients from underserved communities in New York City.

 

2) DepCare

 

 

Sustainable models for integrating mental health in primary care have been limited by suboptimal mental health screening, lack of primary care provider time for quality discussions, limited resources/access and patient stigma and treatment misconceptions. In response, a multidisciplinary team of providers, patients, and mental health workers in the ACN created DepCare, a personalized, culturally tailored, web-based application aimed at improving depression screening, education and management in primary care settings. DepCare uses a crossover design to test a multi-level optimization strategy centered around a tool for improving screening, patient activation, and automated shared decision-making, as well as provider education/feedback, to improve the delivery of care for depression by internists in primary care clinics across NYPH. The intervention combines cutting-edge implementation science methods, based on transtheoretical behavioral change frameworks and user-centered design principles, to design an intervention tailored to address patient-, provider- and clinic-level barriers to maximize depression treatment optimization (AHRQ Moise PI).

 

3) iHeart Depcare

 

Despite extensive research on the relationship between depression and heart disease mortality, heart disease patients remained sub-optimally screened and treated for depression. iHeart tests a theory-informed multi-level implementation strategy centered around patient activation with the goal of improving the uptake of depression treatment and reducing maladaptive behaviors in coronary heart disease patients (NHLBI PI Moise).

3a) Multi-level Determinants and Strategies for the Implementation of Homebased Cardiac Rehabilitation among Acute Coronary Syndrome Survivors 

The goal of this project is to identify multi-level factors that influence the implementation of home-based cardiac rehabilitation and to develop strategies to increase cardiac rehabilitation participation among cardiac patients (NLHBI Investigator Research Supplement, PI Duran).

 

4) StepWell: Stepped Care Mental Health and Substance Use Telehealth Services for COVID-19 Affected Patients

 

The goal of this study is to develop and test the feasibility and effectiveness of a mental health and substance abuse disorder screening, triage, and remote stepped care web application on long-term quality of life outcomes among COVID19 survivors and their families (NIMH supplement; PI Wainberg, Moise).

 

5) De-implementation of Mammography Overuse in Older Racially and Ethnically Diverse Women

De-implementation is recognized as a critical but understudied area within implementation science (IS). Research is needed to determine the optimal methods and approaches for identifying, selecting, and tailoring de-implementation strategies. De-implementation of routine cancer screening in older adults, such as mammography screening for breast cancer, offers excellent opportunities for both advancing the science of de-implementation and improving care delivery and health outcomes in older adults (MPI Tehranifar, Shelton, Moise).

 

6) Implementing Telehealth-enhanced Hybrid Cardiac Rehabilitation (THCR) among Acute Coronary Syndrome Survivors: A Pilot Randomized Controlled Trial

Cardiac Rehabilitation (CR)—which involves exercise training and health behavior modification in clinic- and/or home-based settings—is a Class I, Level A secondary prevention program that significantly reduces reinfarction and mortality rates in acute coronary syndrome (ACS) survivors. Yet, fewer than 30% of eligible cardiac patients participate in CR programs in the United States. Given the unprecedented impact of COVID-19 on our healthcare system, CR participation has declined even further.

One promising avenue for increasing CR participation in the post-COVID-19 era is a telehealth-enhanced hybrid CR (THCR) model, combining telehealth, clinic- and home-based CR. The degree and optimal design (e.g., frequency/duration of home- vs. clinic-based sessions) by which THCR improves clinical outcomes among ACS survivors remains unknown. Moreover, few if any studies have examined how best to address patient, provider, and organizational barriers to implementing a THCR model in ACS patients. This project launches an interdisciplinary program of research across the fields of implementation science, behavioral medicine, telehealth, and exercise physiology to address these gaps.

The goals of this pilot study are to (1) test the feasibility of conducting a single center, two-arm, 1:1 parallel group randomized clinical trial of THCR compared with traditional CR in ACS survivors, and (2) investigate multi-level barriers and facilitators to implementing THCR among this population. These results will then be used to develop theory-informed, multilevel implementation strategies in a future hybrid type II effectiveness-implementation trial (KL2 TR001874, NIH/NCATS, PI Duran).