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Trials. 2018 Aug 22;19(1):453. doi: 10.1186/s13063-018-2817-y.

A dynamic application of PRECIS-2 to evaluate implementation in a pragmatic, cluster randomized clinical trial in two nursing home systems.

Author information

1
Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. jennypalmer@hsl.harvard.edu.
2
Hebrew SeniorLife, Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. jennypalmer@hsl.harvard.edu.
3
Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA. jennypalmer@hsl.harvard.edu.
4
Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.
5
Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main Street, Providence, RI, 02903, USA.
6
Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
7
Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.
8
Massachusetts General Hospital, Section of General Medicine, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA.
9
Hebrew SeniorLife, Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.
10
Beth Israel Deaconess Medical Center, Department of Medicine, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.

Abstract

BACKGROUND:

PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary-2) can assess how clinical trial design decisions (along the explanatory-pragmatic continuum) influence the applicability of trial results to intended stakeholders. The tool has been used to assess features of trials during the trial design phase and also upon completion. The ongoing PRagmatic trial Of Video Education in Nursing homes (PROVEN), which is evaluating the effectiveness of a suite of videos to improve advance care planning, is one of the first large pragmatic, cluster randomized trials within nursing home health care systems. While certain features of pragmatic trials remain static once designed (e.g., recruitment, outcomes), successful implementation of a system-wide program requires on-going evaluation and adaptation. This report's objectives were to apply PRECIS-2 in a novel manner during the actual conduct of the PROVEN trial to assess how dynamic adaptations shifted implementation to either a more explanatory or a more pragmatic approach.

METHODS:

We assessed PROVEN's protocol as initially designed according to the three PRECIS-2 domains pertinent to implementation: (1) Organization, (2) Flexibility-Delivery, and (3) Flexibility-Adherence. We then applied this framework to conduct a formative evaluation of decisions made while the trial was ongoing to adapt the implementation approach along the pragmatic versus the explanatory continuum in response to emergent challenges.

RESULTS:

Based on the PRECIS-2 rubric, the initial design of the PROVEN implementation approach reflected a hybrid of pragmatic and explanatory features. Most notably, within the Flexibility-Delivery, the trial had a relatively pragmatic approach to protocol delivery by front-line nursing home providers, balanced with a more explanatory approach to protocol monitoring enabled by the analytic capabilities of the research team. This more intensive monitoring proved critical in revealing implementation problems once the study began. Dynamic adaptations made in response to these challenges generally reflected shifts to more explanatory approaches within the Flexibility-Delivery and Flexibility-Adherence domains including ever more intensive compliance monitoring, as well as detailed coaching of front-line providers delivering the intervention by the research team.

CONCLUSIONS:

Pragmatic trials conducted in the nursing home setting may benefit from a more dynamic approach to implementation. Allowing fluidity between pragmatic and explanatory features may still preserve the trial's applicability to intended stakeholders' needs. PRECIS-2 provides a useful formative evaluation tool to assess these adaptations in "real-time."

TRIAL REGISTRATION:

US National Library of Medicine, ClinicalTrials.gov, ID: NCT02612688 . Registered on 19 November 2015.

KEYWORDS:

Implementation; Nursing homes; PRECIS-2; Pragmatic trial

PMID:
30134976
PMCID:
PMC6106941
DOI:
10.1186/s13063-018-2817-y
[Indexed for MEDLINE]
Free PMC Article

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