Table 1 Adaptation implications and considerations for cost measurement, organized by the Framework for Reporting Adaptations and Modifications (FRAME) [6]
From: The economics of adaptations to evidence-based practices
Domain/construct | Example | Cost relevance/implications | Considerations for cost measurement | Planned vs. unplanned |
|---|---|---|---|---|
1. Timing | Adaptation occurs in the pre-implementation or planning phase vs. implementation phase | Early-phase adaptations, especially prior to implementation, may be less costly than late-phase adaptations | Time of initiation, frequency, and duration period of adaptation. These may vary across sites due to capacity | More difficult to capture time variables in unplanned adaptations |
2. Planning level | Unplanned/reactive vs. planned/proactive | Unplanned adaptations may require additional resources not originally budgeted for. Alternatively, unplanned adaptations may reduce costs when they are aimed at improving efficiency during the implementation process | Appropriate data capture strategy is imperative for assessing continual iteration on the adaptation to measure incremental cost on the margin (reactively or proactively) | Reporting system is already in place for measuring planned adaptations; reporting system for unplanned adaptation may be created impromptu |
3. Decision-maker | Funder or payer vs. other stakeholders (e.g., political leader, clinician, intervention recipient) | A funder/payer involved in the decision to adapt may be more cost-conscious than another stakeholder who is less affected by costs | Estimated cost impact of adaptation may be contrary to what was anticipated | Projected changes in cost due to planned adaptations could be estimated in BIA a priori for funder buy-in to keep/change decision |
4. Adaptation focus | Adaptation to the EBP vs. implementation strategy | Adapting complex implementation strategies may be more costly than adapting less-complex strategies | Delineating adaptation costs of implementation vs. EBP is crucial for extrapolation/scaling. Variation in adaptation costs may be related to the complexity of the intervention | Projected changes in cost due to planned adaptations to implementation vs. EBP could be estimated a priori for budgeting purposes |
5. Delivery level | Individual patient/participant vs. clinic/unit level vs. organization/health system | Adaptations at the individual patient level may have a low unit cost but lead to high total cost when extend to a patient population, whereas higher level adaptations may involve costly adaptations to infrastructure | Depending on the delivery level; new data collection on direct, both fixed and variable, and indirect costs may be needed to assess adaptation costs. Effects on unit cost may be more difficult to interpret at higher levels | Projected changes in cost due to planned adaptations in delivery level could be estimated a priori for budgeting |
6. Nature of content adaptation | Tailoring or refining, adding or removing elements, shortening or lengthening | Extending the intervention or implementation strategy may result in higher cost whereas condensing it may result in lower cost | May require mixed methods to collect all data necessary for accurately discerning the nature of the adaptation | Need for both quantitative and qualitative data may be particularly acute for unplanned adaptations where context is not well-known |
7. Relationship to fidelity | Adaptation that preserves core elements vs. one that fails to do so | Departure from core elements may increase cost if additional element(s) are needed or reduce cost if certain element(s) are no longer needed when implementing in a new context | May require mixed methods to collect all data necessary for accurately discerning the nature of the adaptation | May need to consider loss of more sites, providers, and/or patients with unplanned adaptation |
8. Reason or motivation | Increase reach or engagement, improve fit, reduce cost | Motivations for the adaptation (i.e., increasing positive outcomes) may also increase cost. Determining when, why, and how reduced costs align with other motivations should be addressed at the outset | Estimated cost impact of adaptation may be contrary to what was anticipated | Projected changes in cost due to planned adaptations could be estimated a priori to support or refute reasoning for adaptation |