The Tailored Implementation in Chronic Diseases (TICD) project: introduction and main findings
Wensing Implementation Science
The Tailored Implementation in Chronic Diseases (TICD) project: introduction and main findings
Michel Wensing 0 1
0 Radboud University Medical Centre, Radboud Institute of Health Sciences , Nijmegen , Netherlands
1 Heidelberg University Hospital, Department of General Practice and Health Services Research , Heidelberg , Germany
Background: The Tailored Implementation in Chronic Diseases (TICD) project aims to contribute knowledge on how to improve healthcare for patients with chronic diseases and, at the same time, knowledge on concepts and methods of tailoring interventions to local conditions. In this contribution, the project is briefly introduced and its main findings are discussed. Discussion: The tailored implementation programs in the TICD project had little impact, for which we provide a range of potential explanations. Structured group interviews with informed stakeholders, such as clinicians and researchers, were used to generate perceived determinants of practice and suggestions for tailored implementation strategies. They were productive and valid, yet incomplete, if compared to perceptions of healthcare providers who received the tailored implementation programs. Ongoing monitoring of determinants of practice during intervention delivery seems required to adapt the interventions to emerging needs and opportunities.
Barriers and facilitators for implementation; Intervention development; Implementation science; Evidence-based healthcare
The implementation of innovations into healthcare practice
remains difficult, despite several decades of scientific
research and development. It is widely felt that
implementation strategies need to be tailored to local needs
and opportunities for change . Tailoring means
“making fit with individual customers”, who are typically
healthcare providers in this context. Analysis of published
tailored implementation programs showed that a wide
variety of approaches and methods for tailoring were
applied , while there is little guidance on their
usefulness. The Tailored Implementation in Chronic Diseases
(TICD) project was a European research project, funded
under the European Community Seventh Framework
during the years 2011–2015. Its aim was to assess tailored
programs to improve healthcare for patients with
chronic diseases (mainly in primary care settings), while
at the same time contributing knowledge on concepts
and methods of tailoring interventions.
A study protocol describes the outline of the project
in detail ; its mean features are summarised here. The
TICD project was informed by reviews of published
research on tailored implementation and an update of
the Cochrane review on tailored interventions (now
covering 32 studies) that was done as part of the project
. The empirical research in the TICD project comprised
of five separate research projects, concerning
multimorbidity (Germany), vascular conditions (Netherlands),
depression in the elderly (Norway), chronic
obstructive pulmonary disease (Poland) and obesity (United
Kingdom). In each of the countries, specific goals for
improving healthcare for the targeted condition were
chosen as targets throughout the project. Given the
targeted chronic conditions, all studies focused on
primary medical care. In each of the five countries,
three studies were performed consecutively:
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(a) an exploration of determinants of practice regarding
the targeted conditions, using interviews and surveys
with healthcare providers;
(b)group interviews with various stakeholders to collect
suggestions for educational, organisational and other
interventions to address determinants of practice;
(c) cluster randomised trials of a tailored
implementation program, based on insight into
determinants and interventions, and related
process evaluations (evaluations of processes
leading to outcomes).
The trials were statistically powered to detect effects
on primary outcomes and not necessarily for post hoc
analyses. The sample sizes were reasonably large (several
hundreds of patients in each trial), but in line with the
confirmatory approach, we have been careful with post
hoc analyses of outcomes. Changes on determinants of
practice, which are basically mediating or moderating
factors for intervention effects, were subject of the process
evaluations. “Determinants of practice” was chosen as the
overall concept, which covers barriers, obstacles,
facilitators and enablers for implementation. Examples include
lack of knowledge, disagreement with recommendations
or anticipated resistance in patients. Specific findings
are presented in separate publications, most of which
have been brought together in a collection of articles
in Implementation Science. In this contribution, the
main findings and lessons from the research project
Developing tailored interventions
Group methods, such as brainstorming and focus groups,
with healthcare providers and others, were productive in
terms of generating items. Many of the suggested
determinants and strategies were recognised as valid by health
professionals, who had been exposed to the
implementation programs that were based on the group interviews
. This finding suggests that structured group methods
in stakeholders can effectively identify determinants of
practice and related interventions. Nevertheless, new
items emerged during the exposure to implementation
programs. Continued monitoring and adaptation of
interventions during their delivery seems also required
to address missed or non-prioritised key determinants,
which was observed in the process evaluation. It should
be noted that we measured perceptions with interviews
and questionnaires in both studies; these may not
completely reflect real determinants of practice and change.
In pragmatic field studies in healthcare; however, it is
difficult to assess determinants of behaviours feasibly in
We had not anticipated the large volume of items
generated in the interviews, so we had not planned for
this and used a pragmatic method for choosing key
determinants and strategies for addressing those. Items
were clustered in conceptual categories , but the
choice of priorities focused on single items. More
systematic methods for prioritisation of items are
recommended to future projects. On the other hand, different
stakeholders seemed to provide largely the same ideas in
interviews, although an important caveat is that we did
not involve patients in all countries. The involvement of
various stakeholders (clinicians, patients, purchasers,
researchers) may have benefits for the perceived credibility
of the chosen interventions, but this has to be balanced
with the additional effort and costs. It may be most
crucial for the credibility of a program to involve the
targeted groups in the final choice of interventions. Also,
some group activities may be primarily designed to
enhance engagement of stakeholders rather than to add
information that is crucial for the design of programs.
An alternative approach to tailored implementation is
the use of existing theory on change of behaviour and
organisations. In the TICD project, we used a broad
theories-orientated framework to guide interviews and
analysis . Given its comprehensiveness and high level of
specification, this conceptual framework is itself an
important contribution to implementation science. Other
researchers used more narrowly defined theories, for
instance from psychology, more closely in the design and
evaluation of interventions. In the TICD project, however,
we felt that no theory convincingly could explain the
organisation and delivery of healthcare for patients with
chronic diseases. This reflects the current state of science,
which is that knowledge of determinants of individual and
organisational behaviours is limited.
Tailored interventions in practice
The tailored implementation programs resulted in
improvements on some outcomes, but they had overall little
observable impact on primary or secondary outcomes.
Table 1 summarises potential reasons for lack of effects,
based on discussions in the TICD project group in February
2015. We considered these reasons plausible hypotheses.
It has been argued that medical care is often complex,
meaning that many processes influence the outcomes in
unpredictable ways. Measures can only partly capture
these complexities, and measures based on clinical or
administrative records may unable to catch specific
changes in clinical decision making and counselling of
patients . The significant effects on some outcomes
may be interpreted as indication that change occurred,
but it should be noted that we also found evidence of
deterioration on other outcomes. It may also be possible
that general trends in the health systems, particularly those
concerning reimbursement or politics on health
professions, had impacts that overruled our implementation
Table 1 Potential reasons for lack of effects in the TICD trials
Research evidence for some recommended clinical activities, which
were targeted in the trails, is limited or mixed. Therefore, these
recommendations might not have been credible for the targeted
The list of identified and targeted determinants of practice was not
complete, so we might have failed to address key factors in the
implementation programs. In addition, some determinants could not
be adapted in the context of the TICD project, such as payments and
organisation of healthcare delivery.
The chosen implementation strategies were not sufficiently matched
with targeted determinants, or not effective in the targeted groups and
settings. Insight into the linkages of interventions and determinants
is very limited.
Health professionals’ agreement to participate in the implementation
program was not a good predictor of intention to change behaviour.
For instance, there are many competing priorities or participants may
felt little ownership of the program, despite the tailoring.
The provided tailored interventions were not used, thus could
not have impact. The fidelity of the implementation programs was
Determinants, interventions and contextual factors interacted in complex
ways, which reduced their impact. For instance, treatment targets for
vascular risk may be used flexible in patients with complex morbidities.
The primary outcomes were not adequately chosen, for instance
because they were largely dependent on patents’ biology, or the
available measures lacked responsiveness to change.
The follow-up period in the TICD trials was too short to detect change,
as most changes require much more time to happen.
The pragmatic trials involved heterogeneous populations and low
control of intervention delivery, which has reduced impact and hidden
impact in subpopulations.
Contextual factors led to improvements in the control groups, thus
reducing the added value of the tailored implementation programs.
programs. For instance, GP-centred care programs in
Germany and chronic care groups in the Netherlands are
major contextual influences, also because they include
additional reimbursement for some of the activities that
It seems that the targeted health professionals used
the implementation programs as a menu of options,
from which they chose as felt necessary. It seems
important to invest more in the uptake of the
implementation interventions, perhaps by using hierarchical power
or by providing strong financial incentives and thus
increase implementation fidelity. However, this raises
issues of professional autonomy and person-centred
care. An alternative is to tailor interventions more
intensively to individual users and specific organisations
(“personalized implementation”), but this can be very costly.
To be a realistic option for application outside scientific
studies, it would require more efficient methods than
individual or group interviews.
The TICD project focused on improving primary medical
care for patients with chronic diseases. To what extent are
its findings and tools valid in other populations and
settings is an open question. For instance, in some other
settings, the role of managers may be crucial , while it
is limited in primary care that is delivered in office-based
practices. It seems plausible that these are generalizable
across a range of healthcare settings, and possibly beyond,
but this claim has yet to be supported by empirical
research. Overall, the TICD project raises concerns about
tailoring as a recommended approach to implementation
of innovations in healthcare practice.
The project is one of the first studies on methods for
tailoring strategies for improving healthcare in
implementation science. The project opens a field of research,
with many unanswered questions. We did not focus on
the use of resources by different methods, but this is
obviously an important topic for future research. The
efficiency of tailored implementation may be enhanced
by separating out the identification of items (which may
be best done with informed key people) and other
activities to involve stakeholders for enhancing the credibility
of the approach. An important question is also how to
prioritise determinants of practice and tailored
interventions from a large number of suggested ones. It is also
important to explore how tailoring (or adaptation) of
interventions during their delivery is done, if at all.
It is difficult to provide firm take-home message for
users of tailored interventions, given the limited
evidence on tailoring methods and the absence of impact
on outcomes in the trials. Some findings were striking.
Structured group interviews of 2 h each with 3–7
wellinformed individuals, such as healthcare providers and
researchers in the field, were productive and seemed
valid. Nevertheless, it would be desirable to experiment
with different sampling and interview methods in future
research in order to examine what is most effective and
efficient. Ongoing monitoring of determinants of
practice during intervention delivery seems required to adapt
the interventions to emerging needs and opportunities.
This is consistent with recent theoretical work, which
suggests that adaptation of intervention is crucial given
contextual and political changes . However, it poses
a tension with the requirements for summative
evaluation, e.g. randomised trials, which require a high degree
of standardisation of the intervention for a meaningful
interpretation. Tailoring interventions to local conditions
makes sense intuitively, but there is as yet no evidence
to expect strong effects on outcomes.
The study is funded by the European Union Seventh Framework
Programme (FP7/2007–2013) under grant agreement no. 258837. The
Netherlands Organization for Health Research (ZonMW) provided
additional funding under grant 200310011. The funders had no role
in the study design, data collection and analysis, decision to publish or
preparation of the manuscript.
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