Article Text

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments
  1. Mitchell N Sarkies1,
  2. Emilie Francis-Auton1,
  3. Janet C Long1,
  4. Andrew Partington2,
  5. Chiara Pomare1,
  6. Hoa Mi Nguyen1,
  7. Wendy Wu1,
  8. Johanna Westbrook1,
  9. Richard O Day3,4,
  10. Jean-Frederic Levesque5,6,
  11. Rebecca Mitchell1,
  12. Frances Rapport1,
  13. Henry Cutler2,
  14. Yvonne Tran1,
  15. Robyn Clay-Williams1,
  16. Diane E Watson5,
  17. Gaston Arnolda1,
  18. Peter D Hibbert1,7,
  19. Reidar Lystad1,
  20. Virginia Mumford1,
  21. George Leipnik8,
  22. Kim Sutherland9,
  23. Rebecca Hardwick10,
  24. Jeffrey Braithwaite1
  1. 1Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
  2. 2Centre for the Health Economy, Macquarie University, Macquarie Park, New South Wales, Australia
  3. 3Clinical Pharmacology, St Vincents Hospital Sydney, Darlinghurst, New South Wales, Australia
  4. 4Pharmacology, University of New South Wales, Kensington, New South Wales, Australia
  5. 5Bureau of Health Information, St Leonards, New South Wales, Australia
  6. 6Centre for Primary Health Care and Equity, University of New South Wales, Kensington, New South Wales, Australia
  7. 7University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
  8. 8New South Wales Ministry of Health, St Leonards, New South Wales, Australia
  9. 9New South Wales Agency for Clinical Innovation, St Leonards, New South Wales, Australia
  10. 10Medical School, University of Exeter, Exeter, Devon, UK
  1. Correspondence to Dr Mitchell N Sarkies; Mitchell.sarkies{at}


Introduction Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

Methods and analysis This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

Ethics and dissemination Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

  • health services administration & management
  • heart failure
  • diabetic foot
  • general diabetes
  • end stage renal failure
  • bone diseases

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  • Twitter @JanetCLong, @jfredlevesque, @HealthDataProf, @RClaywilliams, @DrDianeWatson, @RLystad, @kimlsutherland3

  • Contributors JB, J-FL, DEW, HC, ROD, RM, FR, YT, RC-W and JW initiated the project partnership, conceptualised the project and obtained funding. JB, MNS, J-FL, EFA, AP, J-FL and DEW were responsible for the overall study design. Initial drafting of the protocol was by JB, MNS, EFA, J-FL, with input from all other authors (CP, HMN, WW, JW, RC-W, JW, ROD, JF-L, RM, FR, HC, YT, DEW, GA, PDH, RL, VM, GL, KS and RH). All authors read and approved the final manuscript.

  • Funding This work was supported by the Medical Research Future Fund (MRFF) (APP1178554, CI Braithwaite). The funding arrangement ensured the funder has not and will not have any role in study design, collection, management, analysis and interpretation of data, drafting of manuscripts and decision to submit for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.