Evaluation of a Covariate-Constrained Randomization Procedure in Stepped Wedge Cluster Randomized Trials

Posted on July 23, 2020July 30, 2020 by coprhcon

METHODS

Adapting a method used in cluster-randomized trials, we propose a covariate-constrained randomization method to be used in SW designs. First, we define a balance metric to be calculated for all possible randomizations of cluster order for a given SW design (denoted BSW). The resulting distribution of this balance metric across all possible randomizations is used to select a candidate set of randomizations with acceptable covariate balance, for example, the best tenth percentile (P10) of the BSW distribution. One cluster order is selected at random from this candidate set to be used as the cluster order for treatment implementation. In a simulation study, we implement the covariate-constrained randomization procedure and computed treatment effect estimates and average absolute bias, and estimates of type I error and power. We used these outcomes to evaluate differing cutoffs of the BSW distribution used to define the candidate set and various analysis methods, under varying SW design and confounding settings.

RESULTS

We observed optimal statistical properties when the balance metric was used to exclude a small set of potential randomizations with the highest level of imbalance, and when analysis methods were adjusted for the potential confounders (see Figure for average absolute bias by BSW cutoff results). The covariate-constrained randomization was most beneficial in settings with a small number of clusters, low intra-class correlation, a low number of participants per cluster, and in the presence of cluster-level confounding variables.

Data Dashboard + Nudge Emails

Posted on July 23, 2020July 30, 2020 by coprhcon

BACKGROUND

Data dashboards are a common audit and feedback approach to support changes in processes and behavior. The rural Transitions Nurse Program (TNP) is a care coordination intervention for high-risk Veterans. An interactive dashboard was used to provide real-time performance metrics to sites. The feedback goal was to increase TNP Veteran discharges. One-year post implementation, discharge goals were not met. Control theory suggests that feedback using diverse methods can positively influence performance. Nudge emails can draw attention to performance metrics to improve awareness of current state. This study evaluated whether Veteran discharges and site communication increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone.

RESULTS

Our sample included four VA medical centers. The average weekly discharges for all sites during the ~20-month dashboard phase was 4.23 Veterans. The weekly average during the 3-month dashboard plus nudge email phase was 4.21 Veterans. The difference in means was -0.03 (p=0.73). Adjusting for time trends had no further effect. Project time to create and communicate nudge emails was ~14 hours over 3 months. Four nurses responded to the survey. Two reported neutral and two reported positive perceptions of the nudge emails. No site champions responded to the survey.

Development of a Dissemination and Implementation Framework for an Early Childhood Obesity Prevention Program

Posted on July 23, 2020July 30, 2020 by coprhcon

BACKGROUND

Dissemination and implementation (D&I) research addresses the disconnect between evidence-based research and practical application in community settings. Many current evaluation approaches to school-based health programs have a limited focus on outcome measures. This neglects to account for additional factors that influence implementation and program success. The mixed effectiveness of early childhood education (ECE)-based obesity prevention programs and the complexity added by implementing multi-component programs calls for more comprehensive evaluation, and one that includes factors related to D&I.

RESULTS

The COWP D&I framework was developed to inform the program’s implementation and evaluation efforts. The framework consists of six domains: process, stages of dissemination, system-level and contextual factors, intervention-level factors, structural and participant factors (organizational- and individual-level), and outcomes. Preliminary work applying the framework was conducted in 2019. A mixed-methods evaluation assessed D&I factors related to the one component of the COWP program: the COWP Policy, System and Environment (PSE) Change process. Findings suggest that the successful implementation of the process may be most impacted by staff attitudes and perceived importance, the current status of wellness policies, and the adaptability of the process to align with center culture and norms. Factors most related to the successful sustainability of this process may be skills, attitudes, support and engagement of the staff and leadership, and the quality rating score of the center.