Contribution to the literature
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Assessment of cost and implementation time required to implement EBPs is centrally relevant to implementation science.
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Costs vary from the perspective of different stakeholder types (e.g., society, healthcare organization, practitioner, delivery staff, participant).
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Key cost-related issues from the perspectives of different stakeholders are summarized, including those such as patients and delivery staff that are often not explicitly identified and included in economic evaluation.
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This article summarizes the application of economic theory to inform multi-level stakeholder perspectives.
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Recommendations are made for future pragmatic research, application of cost assessment, and its use for decision-making with different stakeholder types.
Introduction
Multi-level framework for stakeholder groups
Stakeholder perspective | Key priorities | Example pre-implementation costs | Example implementation costs | Example sustainability costs |
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Policy and economic environment | Incentivize most cost-effective actions; maximize QALYSa | Current market (e.g., capacity, needs assessment); gaps in quality of care | Direct costs (e.g., labor, supplies); factor prices, (fidelity, production scale, distribution, sunk costs); downstream costs [14] | Can provide less reimbursement; consider other incentives; maximize/optimize staff resources |
Organization | Stay within budget; align with the mission | Capital expenses; costs of promotion and recruitment; health information technology (e.g., dashboard development) | Time until recoup investments; return on investment (ROI) [15] | Costs to maintain quality service (e.g., labor; technology support/maintenance) |
Management team: supervisory staff | Effective allocation of staff; efficient workflow, maximizing outcomes given budget constraints | Training costs; infrastructure development | Costs to produce quality results; documenting and logging time and effort | Retraining costs; cost audit and feedback; budget constraints |
Provider team: front line delivery staff | Improve workflow; competing demands; relative benefit of adopting new EBP (time and productivity/outcomes) | Opportunity costs for training, logistics, and preparation for EBP adoption | Time required (e.g., documenting and logging time and effort) | Opportunity costs for ongoing support activities, training; incentives |
Individual participant/patient | Improved health outcomes; competing demand; satisfaction; reduce out of pocket expenses | Travel and time costs; opportunity costs; information costs | Time required on regular basis; | Adherence costs; incentives |
Economic theory and multi-level stakeholder perspectives
Cooperative game theory
Stakeholder engagement
Low-resource contexts
Multi-level perspectives in cost reporting
Case example: multi-level perspectives in implementation science
Frontline providers and organizational perspectives: implementing a fall prevention program
Guidelines for including multiple stakeholder perspectives
Phase | Focus | Recommendation | Hypotheses |
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Preparation (pre-condition) | Identifying multiple stakeholder types | When implementing a new EBP, identify multiple stakeholders across levels who will be impacted by the costs of the implementation. | The inclusion of more stakeholder types initially will set the stage for adopting a multi-level perspective |
Problem exploration (pre-implementation) | Understand cost and benefit issues across identified stakeholder levels | Identify costs and priorities across multiple levels of stakeholder groups. Include a rough estimate of costs and discuss with all stakeholder groups involved. Facilitate meetings to discuss cost data and priorities among different stakeholder groups | Such exploration will aid in developing a deeper understanding of costs and priorities across groups and how they influence adoption, implementation, and sustainment |
Knowledge exploration (pre-implementation) | Identify areas of cost (and benefit) congruence and conflict across stakeholder levels | Provide key cost information related to priorities of each stakeholder group Investigate organizations that have faced similar issues and have successfully resolved them. | Information summaries using visual displays and emphasizing issues prioritized by that group, should aid in identifying areas where conflicts in priorities need to be resolved |
Solution development (pre-implementation) | Identify pragmatic solutions to areas of cost conflict | Facilitate meetings to discuss cost data and priorities, including identifying solutions or reallocation of resources that can be reasonably applied to create win-win scenarios across stakeholder levels | Identifying solutions to resolve incongruencies in stakeholders’ economic priorities will enhance the likelihood of implementation success and EBP sustainment |
Solution testing (implementation) | Assess if the solutions worked to reduce incongruencies in cost priorities, resource allocation | Collect (or estimate) costs regularly: early on; mid-implementation; and 6-8 weeks before the program end; include mixed method evaluation to assess effects on costs/priorities of stakeholders. | Collecting costs and other information at multiple points will be worthwhile to make mid-program adjustments in resource allocation if needed and prepare for sustainment and replication |
Sustainment | Identifying ongoing costs/benefits, mechanisms for sustainment | Using a multi-level approach, identify resources needed to support implementation efforts, plan for resource allocation, and ongoing cost assessment. | Planning for sustainment from a multi-level cost perspective will enhance the likelihood of institutionalization and efficient use of resources. |