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Table 1 Interview questionnaire. Interview Questions Questions for Payers Interviewer provides a brief overview of cancer genomic panels. What is the current state and future direction of the ACO model within your network? What is your perspective on the shift of decision-making on medical technologies to the ACOs? How does this impact ACO decisions on cancer genomic panels, which are not yet covered by payers?

What are the factors that impact ACO decision making on cancer genomic panels and other medical innovations? What are the challenges of decision making and adoption? What are your concerns related to these challenges? What is your perspective on the shift of decision-making on medical innovations to the ACOs?

What are the factors that impact your decision making on cancer genomic panels and other medical innovations? Open in a separate window. Results 3. Growth seen across all geographic areas, ACO types, sizes and settings e. Cost reduction is the primary aim, while controlling for two other aims care quality and patient satisfaction. ACOs should make their own decisions and policies, if they assume partial or full risk.

Coverage policies should retain their current role and define the use of new technologies by ACOs. Payers struggle with decisions on cancer genomic panels and welcome transition of decision making to ACO.

Payers worry about transitioning decisions on cancer genomic panels to ACO due to high cost and downstream impact. ACOs, not payers, should decide whether to monitor utilization of new technologies, according to their internal decisions.

Payers should continue monitoring utilization, especially of expensive technologies such as cancer genomic panels. Payers should stop monitoring utilization of genomic technologies and rely on ACO quality metrics.

Annual scope of cost reductions and metrics limits horizon for longer-term impact of medical innovations. ACO reach cost-reduction plateau; incentive to avoid technologies not required by specific quality metrics, such as cancer genomic panels. ACO metrics focus on generic conditions, relevant to large populations; lack detail necessary for cancer genomic panels. ACO analytical capabilities are limited, accuracy of cost and outcome measurements is a challenge.

Genomics and other innovative technologies could be used by ACOs for marketing to attract patients. Genomics, including cancer genomic panels, continue to be visible and of interest to patients. Conclusions Our findings indicate that ACO proliferation continues under the Triple Aim, and they assume an increasing level of risk and decision authority, including decision on technology adoption.

Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. References 1. The triple aim: care, health, and cost. Health Aff Millwood ; 27 — US House of Representatives.

Section Obama B. Creating accountable care organizations: the extended hospital medical staff. Health Aff Millwood ; 26 :w44—w Skinner J, Chandra A. A national strategy to put accountable care into practice.

Health Aff Millwood ; 29 — The Pioneer accountable care organization model: improving quality and lowering costs. Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. Performance differences in year 1 of pioneer accountable care organizations. N Engl J Med. Health Aff Millwood ; 35 — Berwick DM. ACOs--promise, not panacea.

Accountable care organizations may have difficulty avoiding the failures of integrated delivery networks of the s. Health Aff Millwood ; 31 — Casalino LP. Accountable care organizations--the risk of failure and the risks of success.

Pioneer accountable care organizations: traversing rough country. McClellan M. Accountable care organizations and evidence-based payment reform. Muhlestein D.

Continued growth of public and private accountable care organizations. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff Millwood ; 33 — A framework for evaluating the formation, implementation, and performance of accountable care organizations.

Eddy DM, Shah R. A simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program. Larkin H. ACO or no: how to decide. Hospitals must weigh the benefits and the risks before choosing their paths.

Singer S, Shortell SM. Implementing accountable care organizations: ten potential mistakes and how to learn from them. Tallia AF, Howard J. An academic health center sees both challenges and enabling forces as it creates an accountable care organization. Accountable Care Organizations: how to dress for success.

Am J Manag Care. Teng K. A shift toward personalized healthcare: does the Affordable Care Act provide enough incentive for change? Personalized Medicine. US hospital payment adjustments for innovative technology lag behind those in Germany, France, and Japan. Health Aff Millwood ; 34 — Deverka PA. Pharmacogenomics, evidence, and the role of payers.

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Health Aff Millwood ; 25 — Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. NCCN molecular testing white paper: effectiveness, efficiency, and reimbursement. J Natl Compr Canc Netw. The influence of payer mix on electronic prescribing by physicians.

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Per Med. Health technology assessment and private payers's coverage of personalized medicine. Clinical integration of next generation sequencing: coverage and reimbursement challenges. J Law Med Ethics. What do providers, payers and patients need from comparative effectiveness research on diagnostics? J Comp Eff Res. Challenges of coverage policy development for next-generation tumor sequencing panels: experts and payers weigh in.

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Tumor sequencing takes off, but insurance reimbursement lags. Nat Med. Insurance companies are slow to cover next-generation sequencing. Burns J. Manag Care. Cancer genomics and inherited risk. Robson M. Multigene panel testing: planning the next generation of research studies in clinical cancer genetics. Swisher EM. JAMA Oncol.

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Genet Med. The promise and challenges of next-generation genome sequencing for clinical care. West HJ. Subbiah V, Kurzrock R. Qualitative research practice: A guide for social science students and researchers. Sage; Smith J, Firth J. As our interest was in providing a resource to guide researchers in the process of intervention design, we excluded papers that lacked enough detail for replication. Due to resource limitations, we also excluded articles that were not in English.

An interrater reliability analysis using the Kappa statistic was performed to determine consistency among raters for the full-text review. For all included full texts, general descriptive information authors, year, journal, name of method if so named were extracted and tabulated.

To extract and analyse data about the methods, a two-stage process was carried out. Stage 1 involved generating a framework for data extraction and analysis. Three reviewers HLC, JES, NK progressed in iterative cycles of reading and discussing the included papers to identify similarities and differences between them and used these discussions to develop a list of items to be extracted.

The iterative cycles were continued until an agreement between the three authors was reached. In part, this process was necessary to improve our understanding of the tasks that constitute intervention design and allow us to extract data outside of simply a brief description of the method. The resulting descriptive variables to be extracted were believed to be the most critical, and it included a brief description of the design tasks.

Data extraction was conducted by two individuals HLC, JES independently first followed by consensus discussions for discrepancies Stage 2. Once the duplicates were removed, we had citations to screen Fig. We excluded records based on the title and abstract screen resulting in 64 articles assessed for eligibility with a full-text screen.

Following full-text review and consensus discussion, 49 articles were excluded leaving a total of 15 articles in the review.

The mean Kappa statistic across all pairs was. The context in which the method was developed; either generic described or specific i.

The level of change that the method was focused on i. Whether the method incorporated any other type of published approach, tool, or resource as a component of the design process e. A brief overall description of the tasks included in the method, if the method included barrier identification, if it included a process of component selection that linked barriers to intervention components, the use of theory at any stage of the design process, and whether users were engaged in intervention design i.

Table 1 provides a summary of the included 15 papers that were published between and All 15 included papers specified a context in which the method was initially developed but indicated that the method could be used outside of the particular context; indeed, this was the purpose of the papers.

Thirteen of the 15 papers proposed methods targeting individual HCPs; one of these [ 22 ] proposed methods targeted at the team level but not the organization. Only one paper targeted change across individual, organization, and system levels [ 14 ]. The remaining paper focused on the feasibility of the intervention and not on the change at a specific level per se [ 23 ].

Eleven of the 15 papers incorporated other approaches, tools, or resources as a component of the intervention design process [ 14 , 19 — 28 ]. Five of 15 incorporated just one other published tool [ 20 , 24 , 26 — 28 ], and one incorporated three published tools [ 25 ].

All of the 15 identified papers included a number of tasks required for the design process. These steps ranged from two [ 14 ] to seven [ 28 ] with a median of 5 tasks. All but two [ 22 , 23 ] of the papers included some form of barrier identification. One of these papers [ 22 ] reported an assumption that barriers had already been identified in previous work and provided a method for linking barriers to intervention components. The other paper [ 23 ] focused on adapting an intervention using stakeholder engagement and did not address barrier identification specifically.

Six papers used the structured interview processes outlined in the TDF [ 19 , 21 , 25 ] or in Intervention Mapping [ 20 , 26 , 27 ]. All but two papers [ 23 , 24 ] included linking barriers to intervention components. As mentioned, one of these papers [ 23 ] focused on adapting an intervention using stakeholder engagement and did not address linking to intervention components specifically.

The second paper [ 24 ] did conduct a barriers assessment but did not describe how barriers were linked to intervention components. Methods to link barriers to intervention components included mapping TDF-barriers to the BCT taxonomy [ 19 , 21 , 25 ], as well as using the structured approaches described in Intervention Mapping [ 20 , 26 , 27 ].

All but two papers [ 24 , 32 ] included the use of theory. There were papers e. Other papers used more specific, discrete theories chosen based on the context in which the specific intervention was being developed.

Examples included using Social Cognitive Theory [ 33 ] to design a computer-delivered intervention to enhance the use of practice guidelines in general practices [ 31 ], and using theories of risk perception to improve physical activity in cardiovascular patients as part of the Intervention Mapping process [ 26 ].

All but two papers [ 18 , 30 ] included some approach to gathering input on the design of the intervention from the users or the individuals that were the target of the intervention. In all cases, this involved testing, piloting, or showing the intervention to the targets and gathering feedback in the form of discussion or interview.

In two cases, this included formal cognitive interviews [ 28 , 31 ]. We found 15 papers that outlined 15 methods. All of the papers reported methods that were developed within a specific context.

Thirteen papers targeted only individual HCPs with one paper targeting change across individual, organization, and system levels. The methods consisted of at least two tasks and, at most, seven tasks. Thirteen papers included some form of barrier identification and 13 provided direction for linking barriers to intervention components; however, these were not the same 13 papers.

Thirteen papers included the use of theory, and another 13 included gathering input on the design of the intervention from the targets of the intervention. A number of publications related to designing interventions were not included in this review, For example, MRC guidance documents for developing and evaluating complex interventions [ 9 ], publications outlining the KT process [ 34 , 35 ], tools, and frameworks that examine barriers assessments for KT intervention [ 17 ], and taxonomies of behaviour change techniques [ 10 ].

While these publications are certainly of high relevance to intervention development and evaluation process in general, these were not included here as they were all judged to provide limited detail about the specific, replicable actions to design interventions.

For example, the MRC guidance emphasises the importance of designing interventions, but is limited in concrete guidance on how to actually do this in practice. In addition, a number of papers were identified that specifically stated intervention design as an aim [ 36 , 37 ] but that lacked the detail that would allow replication. It could be that there are additional papers not included in this review that could facilitate intervention design.

While we do not know the rationale for doing so, it could be that existing tools alone are felt to be inadequate for intervention design. Future studies on additional design methods that incorporate other existing tools and resources will likely aid in advancing methodologies for designing interventions.

There were two additional papers not included in our review that received significant dialogue during consensus and therefore warrant some discussion. One of these was Eccles et al. We felt this paper provided a rationale and description of conceptual issues related to using theory to develop an intervention; however, the degree of detail on how to design an intervention in this paper is limited.

The second paper warranting discussion was on Intervention Mapping [ 29 ]. Two main gaps seem evident in our review of the intervention design literature.

First, limited methods target change in organisations or systems, or at least were developed with a focus on the organization or system. We found only one study [ 14 ] that did this explicitly.

A second study [ 22 ] targeted teams as well as individuals but did not do so at the organizational level. We found limited methods to specifically take the organisation and system level contexts into consideration, as well as methods that consider all levels.

Future studies should consider how and under what circumstances to ensure that organisational and system level change is considered. The process of undertaking this review highlights a second gap: the need for a better understanding of what activities constitute intervention design.

Our iterative process of determining the intervention design variables for extraction and the subsequent extraction of those variables has led to a better understanding of the steps inherent in intervention design, at least according to current methods. There appear to be four steps common to intervention design: barrier identification, linking barriers to intervention component selection, use of theory, and user engagement i.

While we do not necessarily understand the best order for these tasks nor do we know what additional tasks are required, it does represent a simple structure of potential prototypical steps for the design of a KT intervention. Additional understanding of these tasks, as well as a more in-depth consideration of potentially additional tasks that should be but are not yet routinely adopted, would improve intervention design methods.

Selecting one of these published methods or building on these methods is likely to guide researchers to use theory. Our review did not measure the degree to which these methods are used but this would be a useful future area of research. Additionally, future methodological work could focus on best practices for the use of theory to design an intervention. Several limitations of this review warrant discussion.

We used only one rater for the title and abstract review. Although support exists for the validity of using one rater [ 41 ], having two raters would have reduced the possibility of omitting a potentially relevant study.

All of the included methods were developed specifically for healthcare environments. This could be in part due to our search strategy. Other methods from disciplines outside of healthcare could yield additional and suitable methods, as could methods developed prior to Several limitations exist that might have reduced the number of potential methods found.

Due to the challenges in adequately searching books, we did not include books or book chapters in our search. Our inclusion criteria meant that we did not include any studies that reported on the testing of an intervention in addition to the development of the intervention. In part, we did this to isolate methods that were described in enough detail to be able to replicate and adequately guide the design of an intervention.

Lastly, we did not search grey literature, making the review susceptible to publication bias [ 42 ], and we only chose to use three databases. It is feasible that additional methods exist. Its use as a resource and as a catalyst for improved quality and quantity of methods is encouraged.

Although these methods included varied steps, there was a general agreement that designing an intervention for individual-level change includes identifying barriers, selecting intervention components, using theory, and engaging end-users. Methods for designing organisation and system-level interventions were limited. Further comparative analysis of how the common tasks are completed in the different methods will provide a starting point for developing more detailed guidelines for designing KT interventions.

Future research should focus on the degree to which these methods have been used, determining how such methods could be better adopted and further development of both guidance for the existing methods and, potentially, new methods. Canadian Institutes of Health Research. About knowledge translation.

Knowledge translation of research findings. Implement Sci. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Local opinion leaders: effects on professional practice and health care outcomes.

Cochrane Database Syst Rev. Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev. Article Google Scholar. Using theory to synthesise evidence from behaviour change interventions: the example of audit and feedback. Soc Sci Med. Do published studies of educational outreach provide documentation of potentially important characteristics? Am J Med Qual. Article PubMed Google Scholar.

Developing and evaluating complex interventions: the new Medical Research Council guidance. The behavior change technique taxonomy v1 of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions.

Ann Behav Med. Knowledge translation in health care: moving from evidence to practice. What counts as evidence in evidence-based practice? J Adv Nurs. Better reporting of interventions: template for intervention description and replication TIDieR checklist and guide. Validation of the theoretical domains framework for use in behaviour change and implementation research.

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