Andrew Cohen

Background: Strategies to implement evidence-based practices often require modifications. A systematic approach to documenting these changes was not widely adopted until the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS) emerged in 2021, enabling researchers to characterize both proactive and reactive implementation changes. While publications demonstrating the FRAME-IS's application are emerging, few have reflected on the use of the tool itself. The National Institutes of Health-funded Deidentified Opioid Initiative R01 trial, testing strategies to implement the Centers for Disease Control and Prevention guidelines on opioid prescribing, offered a timely chance to assess the FRAME-IS's utility in a multisite, hybrid type-3 trial. Method: An interdisciplinary team of researchers, clinicians, and implementers documented modifications using the FRAME-IS across four implementation strategies that comprise an implementation package called systems consultation: (1) audit and feedback, (2) educational meetings, (3) practice facilitation, and (4) prescriber peer consulting. Modifications were needed due to COVID-19, the rise in telemedicine, changes in opioid prescribing, and healthcare system variations. Results: The Deidentified Opioid Initiative was implemented in 32 clinics within two Midwestern healthcare systems using a sequential, multiple-assignment randomized trial. The implementation team completed the FRAME-IS's seven modules for each strategy's modifications and reflected on the process of using the tool, strengths, and limitations. Conclusions: The team found the FRAME-IS is practical, comprehensive, and user-friendly. It effectively documents modifications and fosters reflection, raising critical questions about implementation. Challenges included role blurring (i.e., researcher/implementer/coordinator), capturing the complexity of cascading modifications (i.e., how one modification leads to another), and a lack of reporting options to capture modifications in a clustered, multisite trial (i.e., clinical staff nested in clinics nested in healthcare systems). Considerations and recommendations from this case study can enhance the FRAME-IS, guide other scholars in its use, and improve the research community's ability to measure the dynamic evolution of implementation strategies systematically. Future research should explore how documented modifications impact implementation outcomes.

The efficacy of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in treating child traumatic stress inspires nationwide dissemination, yet widespread adoption by state systems of care is lagging. A significant barrier is the cost of implementation and maintenance of evidence-based services. Thus, the current study examined the annual costs of mental health services accrued for 90 publiclyinsured, trauma-exposed children from the time they began participation in a TF-CBT implementation project to 1 year after their admission. These costs were compared to those accrued over that same time period by 90 trauma-exposed control children that were matched by demographics and prior mental health services utilization using a propensity score matching algorithm and provided outpatient treatment as usual. Results indicated that (a) 27.5 % of the total cost was attributed to high-end services utilized by only 1.67 % of children; (b) two times more money was spent on low-end mental health services received by the TF-CBT group than the control group, and (c) five times more money was spent on high-end mental health services received by the control group than the TF-CBT group in that year. These data suggest that providing evidence-based trauma-focused outpatient treatment to children with trauma-related problems may offset the eventual need for services that are more restrictive and costly.