Limitations
DISORDER
It is notable that this survey was launched during the period in which COVID cases were rising, prior to availability of vaccines. The participating clinics shifted to primarily virtual visits during the survey period; for some providers, like BHPs, all visits were temporarily virtual. The clinics started to increase in-person health care visits in spring of 2021, shortly after the surveys were closed. This also meant that the researchers could not engage in any in-person activities to inform staff about the survey.This study faced some additional limitations. First, by attempting to capture pre-implementation data, some responses to items about the intervention were speculative by design. The true extent of barriers (or the emergence of unanticipated barriers) was unknowable at the time. Future research could compare pre-implementation data with follow-up data to track barriers over time. Second, methodological limitations include the potential for response bias (e.g., those with the strongest opinions tend to respond) and missing data (with a voluntary survey, it is not realistic to expect high response rates). Additionally, while surveys allow for breadth of data, they do not allow for depth. Knowing this tradeoff, the authors chose to administer a survey in order to gather a breadth of data across members of the three healthcare systems. Alternative approaches, such as interviews, would have made it more difficult to gather data that reflected a wide range of clinic staff roles.Third, while there were some functional differences among clinics systems (for example, one system uses a group format for delivering medications for opioid use disorder while another has more limited capacity for in-house counseling), clinics within systems shared many similarities, which could have contributed to the broad similarities found in survey results. Future research can use mixed method techniques to supplement survey data with interview, or other, data to examine a broader range of research questions. Fourth, CFIR’s menu of constructs is valuable in that it can be tailored to a study’s situation; however, at the same time, it would have been too burdensome to test all 37 CFIR constructs in survey form. That meant some constructs that were less relevant to the context of the CLARO RCT had to be omitted. Finally, analysis was aggregated to the healthcare system level; further research could explore ways of taking a deeper look at individual clinic-level differences while still protecting the confidentiality of staff members.In future studies, researchers can further develop procedures or tools for using pre-implementation CFIR data to inform (1) rapid feedback loops with clinic leadership and (2) implementation strategies. Pre-implementation data can be examined for associations with patient outcomes at a later point in time and can be useful for assessing the generalizability of study findings and planning for future dissemination of collaborative care efforts. Looking at the CFIR data post-implementation can also help to identify features of clinic context that are associated with implementation outcomes; to guide exploration in determining which factors influenced effectiveness outcomes by using the CFIR constructs; and to identify the features of the intervention that were implemented with the greatest success or that were likely to be sustained beyond the RCT.