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Program Evaluation. Presentation by: Kathleen Tebb , PhD Assistant Professor of Pediatrics Division of Adolescent Medicine University of California, San Francisco 11.12.09. Introduction. Eval. Research Examples : Influence of formula gift packs on breastfeeding cessation

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program evaluation

Program Evaluation

Presentation by:

KathleenTebb, PhD

Assistant Professor of Pediatrics

Division of Adolescent Medicine

University of California, San Francisco

11.12.09

introduction
Introduction

Eval. Research Examples:

  • Influence of formula gift packs on breastfeeding cessation
  • Intervention to Improve Infant & Toddler Immunizations
  • Mentoring Program for Teen Mothers & Babies
  • Improving Chlamydia Screening
presentation objectives
Presentation Objectives
  • Review Research Program that Utilized 3 Different Eval. Components
  • Understand & Appreciate the Value of Different Types of Program Eval.
  • Emphasis on Value of Process Evaluation
problem ct the silent epidemic
Problem: CT the Silent Epidemic
  • CT is most common reportable bacterial infection
  • Highest among 15-25 yo females
  • Most infections (70-80%) are asymptomatic
  • Untreated CT can cause PID & sequelae
  • Cost US health system $3-4 bil /yr
  • Easy to test, easy to treat
  • Screening rates remain unacceptably low
what to do
What to do?

Goal: Increase CT Screening Rates

Setting: KP, N CA

  • Large Patient Population
  • Large # of Clinics (randomization)
  • Data Infrastructure, but indv’l clinics similar to small group practices
  • Existing Relationship with key champion
formative evaluation
Formative Evaluation

Step 1:

Needs assessment:

  • Clinician/Staff Barriers
  • SA rates
  • CT screening rates
formative evaluation1
Formative Evaluation

Clinicians Findings:

  • Discomfort speaking to teens about sexual activity
  • Difficulty establishing confidentiality
  • Time constraints – competing priorities
  • Misperceptions about teen SA & CT screening
formative evaluation2
Formative Evaluation

Admin data:

  • Very poor overall CT screening rates
  • Site specific screening rates
formative evaluation3
Formative Evaluation

Step 2: Pilot Test Intervention

  • Friendly/receptive site
  • Close proximity
  • Work out major kinks (implementation/data)
rtc methods
RTC: Methods
  • Step 3: Randomized Clinical Trial of 10 clinics
    • Intervention: 5 Clinics
    • Control: 5 Clinics
slide13

Clinical Practice Improvement Model

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain

slide14

Clinical Practice Improvement Model

  • Leadership
  • Best practices
  • Define gap
  • Raise Awareness

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain

slide15

Clinical Practice Improvement Model

  • ACTeam
  • Skills & tools

Engage

Team Building

Re-Design

Clinical Practice

Sustain the Gain

slide16

Clinical Practice Improvement Model

Engage

  • Customize
  • Define success &
  • measures for it

Team Building

Re-Design Clinical Practice

Sustain the Gain

slide17

Clinical Practice Improvement Model

Engage

  • Monitor performance
  • Continuous improvement

Team Building

Re-Design Clinical Practice

Sustain the Gain

slide18

Rapid Cycle

Changes

  • Establish ACTeam
  • Monthly Meeting
  • Set Goal
  • Identify barriers
  • Decide solution
  • Try it out
  • Assess
  • Repeat “cycle”

% Change in STD Screening Rate

S t a t u s Q u o

Time in months

slide20

Average screening rates & 95% CI by time and group

0.6

Treated

Control

0.4

Proportion screened

0.2

0.0

-2 to 0

0 to 3

3 to 6

6 to 9

Months post-intervention

Shafer, Tebb, et al.

JAMA. 2002

2 process evaluation
2. Process Evaluation
  • Process evaluation examines each component of the intervention implementation
  • How was intervention implemented?
  • Was it implemented as planned?
    • -- Resources used, activities, quality, etc…
slide22

Process Eval: Clinic Flow Chart

Cue

Charts

Vitals

Provider

Encounter

Urines

To Lab

Follow-Up

CT+

ID eligible teens (age/gender)

Charts stamped with cue

Obtain & Record Sex Hx

SA teens give urine sample

Cue MD with Lab Slip

Confidential Contact #

MD gives teen CT info.

Confirm Confidential Contact #

MA refrigerates urine

MA enters info in log book

Runner takes urines to lab

Lab runs CT test

RN contacts CT + teen: confid. #

Teen comes to clinic for Rx

RN enters Rx in STD log book

process eval cont
Process Eval. Cont.
  • Admin Data – clinic records, log books, etc.
  • Regular mtgs with Providers/staff
  • SRA observations
  • Chart review
process evaluation components
Process Evaluation Components

CT Study: Multiple Methods

Direct Observation recorded in log books

1:1 Interviews & monthly team mtgs

Anonymous surveys, staff, providers, teens

Admin Data:

-- clinic records

-- chart reviews

chart review ex
Chart Review Ex.
  • Central laboratory database

– identify consecutive sample

  • Retrospective chart review

– by independent clinician

  • Standardized data tracking form
does identification lead to follow up
Does Identification Lead to Follow-up?

Tracking Form Based on CDC Guidelines

  • Appropriate antibiotics
  • Counseling on safer sex
  • Partner notification and treatment
  • Lab tests for other STI’s
  • Re-test at 3 months & as needed
process eval lesson learned
Process Eval. Lesson Learned

Revealed Important Quality Gaps

  • CT screening lead to Rx but…
  • Successful identification does not always lead to successful management
  • Also… only 1/3 teens WCV in given year

Hwang L., Tebb K., et al. Archives of

Pediatrics & Adolescent Med. 2005

next step
NEXT STEP

CT Screening in UC

Similar intervention approach

Similar evaluation methods

process evaluation cont
Process Evaluation cont.

Determining Failure: Implementation vs. Theory

Implementation failure:

  • Program is not implemented as planned

Theory failure:

  • Program is implemented as planned
  • Intervention does not produce intermediate results, and/or desired outcome
what about the teens
What about the teens?
  • Outcome eval. info about CT screening rate, but no info from patient perspective
  • Anonymous post UC visit survey (N=365)
  • Clinician Communication& Teen Acceptability
what about the teens1
What about the teens?
  • High acceptability
    • Sexual Health 84%
    • Urine CT test 80%
  • Acceptability significantly associated with:
    • Clinician explained confidentiality
    • Knows how to “talk to teens like me”
    • “Listened carefully as I explained my concerns”

Miller K, Tebb K., et al. Archives of Pediatrics & Adolescent Med. 2007

program evaluation challenges
Program Evaluation Challenges
  • Dealing with the “politics” of a program
  • Having program design/policy change mid course
  • Balancing tensions between rigor and practicality (for decision-makers)
  • Multiple stakeholders: clients, clinicians, parents…
  • Obtaining $$ & support for strong designs
lessons learned valuing the process
Lessons Learned: Valuing the Process
  • Gave over-worked staff sense of importance, success & control over workplace
  • Flexible, one solution does not fit all
  • UC more challenging than WC, different settings, different results
  • Identification of specific component processes & resources support TRIP
lessons learned cont
Lessons Learned cont.
  • Multiple evaluation components:
  • lead to a better intervention design;
  • informed the interpretation of results along the way
  • multiple sub-studies, publications, preliminary data, funding support
re aim glasgow 2001
Re-Aim (Glasgow, 2001)
  • Reach, Effectiveness, Adoption, Implementation & Maintenance
  • Approach to address translation of research into practice
  • Examines the robustness or consistency of results across patient, setting, and clinician subgroups, as well as costs
  • www.re-aim.org for more info & sample studies