Identifying and prioritising ‘best bet’ interventions
Implementation interventions typically have several components but conducting multiple trials of every permutation can be wasteful. For example, varying only five elements of audit and feedback (e.g. differing frequencies of feedback) produces 288 combinations—not allowing for replication of studies or the addition of other interventions, such as educational meetings or outreach visits [The Multiphase Optimization Strategy (MOST) offers a methodological approach for building, optimising and evaluating multicomponent interventions. MOST comprises three steps: preparation, laying the groundwork for optimisation by conceptualising and piloting components; optimisation, conducting trials to identify the most promising single or combined intervention components; and evaluation, a definitive randomised trial to assess intervention effectiveness [The Sequential Multiple Assignment Randomized Trial (SMART) allows identification of the best tailoring variables and uses decision rules for adaptive interventions based upon early findings. It is especially suited for building time-varying adaptive interventions. It has been used to tailor the intensity of an intervention to improve uptake of a re-engagement programme for patients with serious mental illness according to site characteristics and initial responses to interventions [The stepped wedge design offers a solution where there is uncertainty, but randomisation to a non-intervention control is unacceptable. It entails introducing an intervention to groups of clusters in a random order. There are no ‘losers’ because all sites eventually receive the intervention. A stepped wedge trial demonstrated that an intervention comprising professional education, informatics to facilitate review and financial incentives reduced high-risk prescribing in general practices [