Barriers and facilitators to successful implementation of cost-effective interventions and the development of the Achieving Cost-Effectiveness in ICU (ACE-ICU) self-assessment toolkit: an international, multidisciplinary modified eDelphi study

Abstract

Cost-effective interventions balance clinical benefits with economic considerations. Several cost-effective interventions in intensive care unit (ICU) settings have been identified, yet little is known about optimal implementation strategies. The aim of this study was to identify barriers and facilitators to the successful implementation of cost-effective interventions in ICUs and to develop a self-assessment toolkit to guide their implementation. We used a 3-round modified eDelphi design involving ICU healthcare professionals (HCPs), with a focus on multinational and multidisciplinary participation. Round 1 was a qualitative survey with two open-ended questions. The qualitative analysis of Round 1 was conducted using an adapted framework analysis. Round 2 included 38 questions, 29 quantitative and 9 qualitative, divided into 5 domains. Round 3 involved only the Steering Committee members to reach consensus on the statements to retain in the final output. This was followed by iterative discussions to provide actionable insights and develop a self-assessment implementation toolkit, the Achieving Cost-Effectiveness in ICUs (ACE-ICU) toolkit. There were 366 respondents in Round 1, and 161 (44%) in Round 2. Approximately two-fifths of respondents were from low- and middle-income countries defined by World Bank-endorsed gross national income per capita. This was followed by Round 3 of the Steering Committee members ( n  = 21). Round 1 and 2 identified 29 key barriers and facilitators across 5 domains: (1) individual HCP-related issues; (2) institutional issues; (3) infrastructure and systems; (4) governance and research; (5) patient and family engagement. Notable similarity was observed across country categories. In Round 3, the consolidated 12-point self-assessment ACE-ICU toolkit was developed and agreed upon, including knowledge, skills, and attitude of HCPs, training standards, budget allocation and implementation within allocated budget, ICU leadership team readiness to embrace cost-effective practices, infrastructure and systems, governance, regulations and incentives, and patient and family engagement. Our study identified 29 key barriers and facilitators, along with actionable guidance to successfully implement cost-effective interventions in ICUs. The observed similarities across country categories suggest that establishing a global framework for this purpose is feasible. The proposed 12-point self-assessment ACE-ICU toolkit will help stakeholders to identify and implement successfully cost-effective interventions in their local ICU context. Clinical trial number: not applicable. Open Science Framework (OSF) Registration DOI: https://doi.org/10.17605/OSF.IO/6U3FZ . Not applicable because this study utilized a Delphi consensus methodology among an expert panel and did not involve prospective assignment of human participants to clinical interventions.