Mapping implementation barriers and facilitators of 29 European pilot projects improving diabetes and cardiovascular care: a blended CFIR-NASSS framework analysis

Background: European policy-makers and healthcare practitioners can no longer avoid the diverse health system challenges following the rising morbidity and mortality from non-communicable diseases. JACARDI, an EU Joint Action, was set up with the aim to reduce the high burden of cardiovascular diseases (CVD) and diabetes in Europe by rolling out multiple pilot projects to support evidence building towards improved CVD and diabetes prevention and management. 29 of those pilots in 11 EU countries implement innovative care models, adopting a proactive, person-centred, integrated care approach. Monitoring their implementation barriers and successes over time is key to support progress in practice and expand the evidence base on non-linear implementation processes of diverse integrated care pathways.

 

Approach: We adopt a comparative multiple case study design, whereby the 29 pilot projects from Belgium (2), Finland (2), France (3), Hungary (2), Iceland (1), Italy (6), Latvia (2), Poland (1), Romania (2), Slovenia (3), and Spain (5) constitute the cases. Implementation data from all 29 pilots is collected through: a) qualitative interviews organised after 1-year implementation, b) a mid-term, self-reported SWOT analysis at 6-months follow-up and c) pilot project diaries which are filled in on a monthly basis by the pilot team. Such diaries we more specifically named the pilot’s implementation monitoring plan, as it tracks self-reported challenges, adoption, adaptation and abandonment of pilot project actions. In order to categorise barriers and facilitators, we perform a framework analysis, blending the Consolidated Framework of Implementation Research (CFIR) and the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework.

 

Results: We expect that the blended NASSS-CFIR framework will be useful to narrow down key domains, describe what are the implementation challenges and successes and map how they evolve over time, during the first year of implementation. Specific focus will be given to the adaptation and abandonment of pilot project actions and how this decision is linked to the level of complexity related to the action itself, its implementation and/or context (inner and outer setting). By adopting a comparative perspective, differences in implementation barriers and successes can be discerned by country, intervention content (including prevention, education, digital health and data sharing, risk assessment, decision support, equity & diversity), target group, stakeholder engagement, and sustainability (actions).

 

Implications: This study will give a rigorous, in-depth overview of key implementation barriers and facilitators during the first year of integrated care implementation projects across Europe. The regular and diverse implementation follow-up methods allow for a longitudinal perspective to implementation across multiple time points. While the implementation plans also consist of explicit sustainability actions, which will be given special consideration to in their supportive role to other actions, the second-year implementation evaluation will further emphasise the pathways towards and outcomes of scale-up, sustainability and spread. The use of the blended CFIR-NASSS framework in this study adds value given its ability to grasp how implementation and its key influencing factors unfold and sustain (or fail) over time and scale.