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Seattle-Denver Center of Innovation (COIN)

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COIN Investigators & Staff

COIN Investigators


Christian D. Helfrich, PhD, MPH
Title: Core Investigator; Dissemination & Implementation Methodologist
Research Associate Professor, University of Washington School of Public Health
Location: Seattle
University of Washington webpage
See Dr. Helfrich's Dimensions profile that includes: publications, grants, datasets, patents and clinical trials
Dr. Helfrich is a Core Investigator with HSR, Research Assistant Professor, Department of Health Services at the University of Washington School of Public Health, and Implementation Research Coordinator for the VA Ischemic Heart Disease Quality Enhancement Research Initiative, a collaboration between VA Health Systems Research and Clinical Operations to speed the adoption and implementation of evidence-based practices for priority conditions among Veterans. Dr. Helfrich is also Chair of the Organizational Function Working Group, a part of the VA Patient Aligned Care Team (PACT). Demonstration Laboratory Coordinating Center, which is tasked with evaluating the implementation of a patient-centered medical home model in VA. His primary research interests are organizational change and implementation science, specifically on assessing organizational readiness to change in the context of evidence-based practices, and factors influencing implementation of large scale initiatives. Dr. Helfrich received his PhD in Health Policy and Management from the University of North Carolina at Chapel Hill, and his MPH from the Department of Health Services at the University of Washington School of Public Health.

The following images visualize Dr. Helfrich's work. The word cloud is drawn from publication titles. The research collaboration map shows research relationships (click the image to enlarge):

Dr. Helfrich's publication titles indicate their primary work is care of Veterans
Word cloud from pub titles
Dr. Helfrich's collaborations are primarily from the University of Washington
Research collaboration map
The following research fields have been used to summarize Dr. Helfrich's publications and grants.
Publications Grants
Clinical Research Health Services
Health Services Clinical Research
Prevention Clinical Trials and Supportive Activities
Behavioral and Social Science Chronic Obstructive Pulmonary Disease
Cardiovascular Mental Health
Heart Disease Lung
Heart Disease - Coronary Heart Disease Behavioral and Social Science
Clinical Trials and Supportive Activities Infectious Diseases
Patient Safety Rare Diseases

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Grants & Funding

AdvanCing High quality COPD care for people with immune dysfunction by implementing Evidence-based management through proactive E-consults (ACHIEVE)

Role: Co-PI with Christian Helfrich; David Au is PI
Chronic obstructive pulmonary disease (COPD) is common and associated with morbidity and mortality in HIV-infected patients. However, COPD is often underdiagnosed, and care is suboptimal.
We propose to test an intervention to proactively support primary care providers of HIV-infected patients and make evidence-based recommendations to improve the care and health of their patients with COPD.
Funder: National Heart, Lung, and Blood Institute
NIH website
Publications of note:
A cross-sectional analysis of diagnosis and management of chronic obstructive pulmonary disease in people living with HIV
Receipt and Predictors of Smoking Cessation Pharmacotherapy among Veterans With and Without HIV
ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (The PRECluDE Consortium): Combatting Chronic Disease Comorbidities in HIV Populations through Implementation Research
Community‐Acquired Pneumonia and Risk of Cardiovascular Events in People Living With HIV

Implementation trial of a coaching intervention to increase the use of transradial PCI

Our goal is to improve the VA’s ability to systematically implement new, technically challenging, evidence-based clinical procedures by testing the effectiveness of a team-based coaching intervention in increasing the implementation of trans-radial access (TRA) cardiac catheterization.
We will also test and refine a conceptual model to better understand how factors underpinning the coaching intervention, such as participant perceptions of TRA, psychological safety, and participant self-efficacy, are associated with TRA implementation.
We will perform a cost analysis of the coaching intervention and effects on costs per episode of care to help establish the business case for the coaching intervention. By increasing the implementation of TRA, relative to the dominant trans-femoral approach, this study can potentially reduce complications, which occur in approximately 2% of cases, by nearly 80% for the about 50,000 Veterans receiving cardiac catheterizations at VA facilities annually.
Funder: Veterans Affairs
NIH website
Publications of note:
Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention

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Recent Publications



Kurlander JE, Laine L, Kim HM, Roberts CB, Saffar D, Myers A, Holleman R, Gao Y, Shank M, Nelson R, Forman J, Helfrich CD, Krein SL, Saini SD, Yang YX. Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. BMJ. 2024 Apr 11;385:e076484. doi: 10.1136/bmj-2023-076484. PMCID: PMC11007585.
PMID: 38604668
Learn more about this publication on Dimensions


Shalev L, Helfrich CD, Ellen M, Avirame K, Eitan R, Rose AJ. Bridging language barriers in developing valid health policy research tools: insights from the translation and validation process of the SHEMESH questionnaire. Isr J Health Policy Res. 2023 Nov 26;12(1):36. doi: 10.1186/s13584-023-00583-8. PMCID: PMC10680279.
PMID: 38008722
Learn more about this publication on Dimensions

Donovan LM, McDowell JA, Pannick AP, Pai J, Bais AF, Plumley R, Wai TH, Grunwald GK, Josey K, Sayre GG, Helfrich CD, Zeliadt SB, Hoerster KD, Ma J, Au DH. Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial). Contemp Clin Trials. 2023 Nov 5;135:107378. doi: 10.1016/j.cct.2023.107378. Epub ahead of print.
PMID: 37935303
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O'Connor AW, Helfrich CD, Nelson KM, Sears JM, Jensen PK, Engstrom C, Wong ES. Full practice authority and burnout among primary care nurse practitioners. Nurs Outlook. 2023 Oct 17;71(6):102056. doi: 10.1016/j.outlook.2023.102056. Epub ahead of print.
PMID: 37856902
Learn more about this publication at Dimensions

Molloy-Paolillo B, Mohr D, Levy DR, Cutrona SL, Anderson E, Rucci J, Helfrich C, Sayre G, Rinne ST. Assessing Electronic Health Record (EHR) Use during a Major EHR Transition: An Innovative Mixed Methods Approach. J Gen Intern Med. 2023 Oct 5. doi: 10.1007/s11606-023-08318-w. Epub ahead of print.
PMID: 37798584
Learn more about this publication at Dimensions

Ives J, Bagchi S, Soo S, Barrow C, Akgün KM, Erlandson KM, Goetz M, Griffith M, Gross R, Hulgan T, Moanna A, Soo Hoo GW, Weintrob A, Wongtrakool C, Adams SV, Sayre G, Helfrich CD, Au DH, Crothers K. Design and methods of a randomized trial testing advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE). Contemp Clin Trials. 2023 Jul 20:107303. doi: 10.1016/j.cct.2023.107303. Epub ahead of print.
PMID: 37481201
Learn more about this publication at Dimensions

Naranjo D, Doll J, Maynard C, Beaver K, Bansal A, Helfrich CD. Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures. J Interv Cardiol. 2023 May 4;2023:2488045. doi: 10.1155/2023/2488045. PMCID: PMC10175015.
PMID: 37181493
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O'Connor AW, Wong ES, Nelson KM, Sears JM, Helfrich CD. Patient Enrollment Growth and Burnout in Primary Care at the Veterans Health Administration. J Gen Intern Med. 2023 Jan 25. doi: 10.1007/s11606-023-08034-5. Epub ahead of print.
PMID: 36697928
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O'Connor AW, Helfrich CD, Nelson KM, Sears JM, Singh H, Wong ES. Changes in electronic notification volume and primary care provider burnout. Am J Manag Care. 2023 Jan;29(1):57-63. doi: 10.37765/ajmc.2023.89304.
PMID: 36716155
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Sanchez A, Elizondo-Alzola U, Pijoan JI, Mediavilla MM, Pablo S, Sainz de Rozas R, Lekue I, Gonzalez-Larragan S, Llarena M, Larrañaga O, Helfrich CD, Grandes G. Applying the behavior change wheel to design de-implementation strategies to reduce low-value statin prescription in primary prevention of cardiovascular disease in primary care. Front Med (Lausanne). 2022 Oct 13;9:967887. doi: 10.3389/fmed.2022.967887. PMCID: PMC9606599.
PMID: 36314033
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Edelman EJ, Gan G, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Helfrich CD, Reynolds J, Yager JE, Morford KL, Muvvala SB, Fiellin DA. Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial. JAMA Netw Open. 2022 Oct 3;5(10):e2236904. doi: 10.1001/jamanetworkopen.2022.36904.
PMID: 36251291
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Fishleder S, Harris JR, Petrescu-Prahova M, Kohn M, Helfrich CD. Development and Feasibility Testing of the Clinical-Community Linkage Self-Assessment Survey for Community Organizations. Front Public Health. 2022 May 20;10:797468. doi: 10.3389/fpubh.2022.797468. PMCID: PMC9163549.
PMID: 35669755
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Doll JA, Beaver K, Naranjo D, Waldo SW, Maynard C, Helfrich CD, Rao SV. Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018. Circ Cardiovasc Qual Outcomes. 2022 Mar 11:CIRCOUTCOMES121008359. doi: 10.1161/CIRCOUTCOMES.121.008359. Epub ahead of print.
PMID: 35272504
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Harris JR, Kava CM, Chan KCG, Kohn MJ, Hammerback K, Parrish AT, Helfrich CD, Hannon PA. Pathways to Employee Outcomes in a Workplace Health Promotion Program. Am J Health Promot. 2022 Jan 4:8901171211066898. doi: 10.1177/08901171211066898. Epub ahead of print.
PMID: 34983199
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Duan KI, Helfrich CD, Rao SV, Neely EL, Sulc CA, Naranjo D, Wong ES. Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention. Implement Sci Commun. 2021 Oct 27;2(1):123. doi: 10.1186/s43058-021-00219-5. PMCID: PMC8554885.
PMID: 34706775.

Beaver K, Naranjo D, Doll J, Maynard C, Taylor L, Plomondon M, Waldo S, Helfrich CD, Rao SV. Design and baseline results of a coaching intervention for implementation of trans-radial access in percutaneous coronary intervention. Contemp Clin Trials. 2021 Oct 25:106606. doi: 10.1016/j.cct.2021.106606. Epub ahead of print.
PMID: 34710590

Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open. 2021 Oct 1;4(10):e2130581. doi: 10.1001/jamanetworkopen.2021.30581.
PMID: 34677595.

Sterling R, Rinne ST, Reddy A, Moldestad M, Kaboli P, Helfrich CD, Henrikson NB, Nelson KM, Kaminetzky C, Wong ES. Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians. J Gen Intern Med. 2021 Jul 29:1–8. doi: 10.1007/s11606-021-07006-x. Epub ahead of print. PMCID: PMC8321506.
PMID: 34327656

Damschroder LJ, Knighton AJ, Griese E, Greene SM, Lozano P, Kilbourne AM, Buist DSM, Crotty K, Elwy AR, Fleisher LA, Gonzales R, Huebschmann AG, Limper HM, Ramalingam NS, Wilemon K, Ho PM, Helfrichfcr CD. Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup. Healthc (Amst). 2021 Jun;8 Suppl 1:100455. doi: 10.1016/j.hjdsi.2020.100455.
PMID: 34175093.

Ailabouni NJ, Reeve E, Helfrich CD, Hilmer SN, Wagenaar BH. Leveraging implementation science to increase the translation of deprescribing evidence into practice. Res Social Adm Pharm. 2021 Jun 6:S1551-7411(21)00184-4. doi: 10.1016/j.sapharm.2021.05.018. Epub ahead of print.
PMID: 34147372

Kononowech J, Hagedorn H, Hall C, Helfrich CD, Lambert-Kerzner AC, Miller SC, Sales AE, Damschroder L. Mapping the organizational readiness to change assessment to the Consolidated Framework for Implementation Research. Implement Sci Commun. 2021 Feb 13;2(1):19. doi: 10.1186/s43058-021-00121-0.
PMID: 33581728



Helfrich CD, Savitz LA. Responding to the Call: a New JGIM Area of Emphasis for Implementation and Quality Improvement Sciences. J Gen Intern Med. 2020 Nov;35(Suppl 2):781-782. doi: 10.1007/s11606-020-06229-8. PMCID: PMC7587537.
PMID: 33106999

Parikh TJ, Stryczek KC, Gillespie C, Sayre GG, Feemster L, Udris E, Majerczyk B, Rinne ST, Wiener RS, Au DH, Helfrich CD. Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids. PLoS One. 2020 Sep 17;15(9):e0238511. doi: 10.1371/journal.pone.0238511. PMCID: PMC7498097.
PMID: 32941462

Simonetti JA, Clinton WL, Taylor L, Mori A, Fihn SD, Helfrich CD, Nelson K. The impact of survey nonresponse on estimates of healthcare employee burnout. Healthc (Amst). 2020 Sep;8(3):100451. doi: 10.1016/j.hjdsi.2020.100451. Epub 2020 Aug 2.
PMID: 32919589

Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. Am J Infect Control. 2020 Nov;48(11):1322-1328. doi: 10.1016/j.ajic.2020.04.024. Epub 2020 May 8. PMCID: PMC7606359.
PMID: 32437753

Winchester DE, Merritt J, Waheed N, Norton H, Manja V, Shah NR, Helfrich CD. Implementation of Appropriate Use Criteria for Cardiology Tests and Procedures: a Systematic Review and Meta-analysis. Eur Heart J Qual Care Clin Outcomes. 2020 Mar 31:qcaa029. doi: 10.1093/ehjqcco/qcaa029. Epub ahead of print.
PMID: 32232436

Gamble-George JC, Longenecker CT, Webel AR, Au DH, Brown AF, Bosworth H, Crothers K, Cunningham WE, Fiscella KA, Hamilton AB, Helfrich CD, Ladapo JA, Luque A, Tobin JN, Wyatt GE; Implementation Research to Develop Interventions for People Living with HIV (PRECluDE) Consortium. ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research. Prog Cardiovasc Dis. 2020 Mar-Apr;63(2):79-91. doi: 10.1016/j.pcad.2020.03.006. Epub 2020 Mar 19. PMCID: PMC7237329.
PMID: 32199901

Brown MC, Harris JR, Hammerback K, Kohn MJ, Parrish AT, Chan GK, Ornelas IJ, Helfrich CD, Hannon PA. Development of a Wellness Committee Implementation Index for Workplace Health Promotion Programs in Small Businesses. Am J Health Promot. 2020 Jul;34(6):614-621. doi: 10.1177/0890117120906967. Epub 2020 Feb 20. PMCID: PMC7305966.
PMID: 32077300

Sanchez A, Pijoan JI, Pablo S, Mediavilla M, de Rozas RS, Lekue I, Gonzalez-Larragan S, Lantaron G, Argote J, García-Álvarez A, Latorre PM, Helfrich CD, Grandes G. Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study. Implement Sci. 2020 Jan 22;15(1):8. doi: 10.1186/s13012-020-0966-3. PMCID: PMC6977270.
PMID: 31969175


Rymer JA, O'Donnell CI, Plomondon ME, Hess PL, Donahue M, Hebert PL, Shroff A, Swaminathan RV, Waldo SW, Seto AH, Helfrich CD, Rao SV. Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program. Am Heart J. 2019 Dec;218:75-83. doi: 10.1016/j.ahj.2019.09.003. Epub 2019 Sep 12.
PMID: 31707331

Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med. 2020 Jan;35(1):51-56. doi: 10.1007/s11606-019-05193-2. Epub 2019 Aug 8. PMCID: PMC6957635.
PMID: 31396814

Parikh TJ, Helfrich CD, Quiñones AR, Marshall-Fabien GL, Makaroun LK, Black MA, Thielke SM. Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients. Medicine (Baltimore). 2019 Aug;98(31):e16469. doi: 10.1097/MD.0000000000016469. PMC6708951
PMID: 31374008

Helfrich CD, Hartmann CW, Parikh TJ, Au DH. Promoting Health Equity through De-Implementation Research. Ethn Dis. 2019 Feb 21;29(Suppl 1):93-96. doi: 10.18865/ed.29.S1.93. eCollection 2019. PMC6428172
PMID: 30906155

Whittington MD, Ho PM, Helfrich CD. Recommendations for the Use of Audit and Feedback to De-Implement Low-Value Care. Am J Med Qual. 2019 Jul/Aug;34(4):409-411. doi: 10.1177/1062860618824153. Epub 2019 Jan 17.
PMID: 30654620

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Media & Art


Christian is famous for his pencil and paper art from conferences he attends. A sampling from his Twitter account, @helfrich_c:

Dr Donna Washington from VA_CSHIIP presenting SeaDenCOIN for R&D grand rounds. Talk on health equity research in DeptVetAffairs. Some striking findings on COVID mortality by race over time, and how disparities changed over time.
Dr. Donna Washington from VA CSHIIP
Julian Brunner from VA CHOIR sharing what frontline clinicians reported on the effects of Cerner EHRM patient safety
Julian Brunner - ARM 23
Paul Hebert talking about how difficult it is to get eviction data, & how we’re facing eviction spike after eviction moratorium.
Paul Hebert - ARM 23
Justin Ricci talking about Cerner training for ⁦VA #ARM2023; EHR users still report significant issues with training at Columbus
Justin Ricci - ARM 23
Dr. Courtney VanHoutven presenting on type III hybrid stepped wedge trial of CONNECT caregiver training intervention
Dr. Courtney VanHoutven
Poppy Shell MPH from Gainesville VA presenting on tailoring Annie text-messaging system for Veterans with diabetes
Poppy Shell MPH
Steve Zeliadt at HSR 2023 reunion
Steve Zeliadt
ARM 2022 dinner with George Sayre, Ellen Ahlness & other VA HSR folks working on Cerner EHR evaluation
George Sayre & Ellen Ahlness
⁦Alex Braga VA CHOIR presenting on employee experience of EHR usability, effect on patient safety & employee burnout before, immediately after Cerner implementation & 10-months later. Pretty grim findings.
⁦Alex Braga - ARM 23
⁦Post-ARM2023 QUERI meeting & session by Christopher Miller on FRAME-IS model for adapting implementation strategy.
⁦Christopher Miller - ARM 23
Jure Baloh presenting on implementation of National Diabetes Prevention Program at Advancing Dissemination and Implementation in Clinical Settings session
Jure Baloh
⁦David Chambers playing D&iTunes D&I Science 2020
⁦David Chambers


Overcoming challenges in de-implementing low-value care: Routines, asymmetry of outcomes, and psychological reactance

by Christian Helfrich, PhD, MPH
19 December 2023

Watch: Overcoming challenges in de-implementing low-value care: Routines, asymmetry of outcomes, and psychological reactance

Some low-value clinical practices persist and are commonly delivered to patients long after evidence has established that the practice fails to benefit patients or poses risks to patients that outweigh any expected benefits. Efforts to systematically reduce low-value clinical practices is sometimes referred to as de-implementation, and many insights from research implementation of evidence-based practices can also be applied to de-implementation. However, de-implementation poses some unique challenges that make it different from efforts to promote the appropriate uptake of new evidence-based practices. This talk explains three unique challenges posed by de-implementation: Routines, asymmetry of outcomes, and psychological reactance. We discuss why these challenges arise, using the example of a provider-randomized trial to reduce inappropriate use of inhaled corticosteroids prescribed to patients with chronic obstructive pulmonary disease. And, we talk about ways to mitigate these challenges, as well as important areas for future research.

Webinar: Applying the PARIHS Framework to Implementation of a Complex Evidence-Based Practice

by Christian Helfrich, PhD, MPH
Seminar date: 9/1/2022

Description: As part of a randomized, controlled implementation trial, study researchers conducted a prospective mixed-methods assessment of the implementation strategy, which was team-based peer coaching, as well as factors influencing implementation of the evidence-base practice, which was the trans-radial approach to cardiac catheterization. This work was guided by the PARIHS framework, supplemented with concepts drawn from other implementation or quality improvement literature. In this presentation, Dr. Helfrich will compare and contrast observations about participants’ experiences of implementing the trans-radial approach, and of the coaching intervention with the PARIHS model, and to describe where findings fit with PARIHS and where they differ. He will examine how the PARIHS framework helps to understand the effect team-based coaching had (and did not have) on participants' implementation of the TRA; and conversely, he will explore what findings suggest about the application of PARIHS to an implementation strategy.

Watch: Applying the PARIHS Framework to Implementation of a Complex Evidence-Based Practice

Find the PDF handout and transcript for Applying the PARIHS Framework to Implementation of a Complex Evidence-Based Practice

Webinar: Results of a Stepped-Wedge Trial of Expert-Coaching to Increase Implementation of the Transradial Approach in Cardiac Catheterizations

by Christian Helfrich, PhD, MPH; Sunil Rao, MD, FACC, FSCAI
Seminar date: 7/27/2022

Description: The transradial approach to cardiac catheterization is a safer, patient-preferred alternative to the historically dominant transfemoral approach. However, there is a well-documented learning curve before cardiologists and catheterization laboratory teams can perform the transradial approach proficiently, which has resulted in very slow adoption in the US. The presenters tested peer-coaching by an experienced catheterization-laboratory team using hands-on training designed to mitigate the learning curve, and assessed whether peer-coaching increased use of the transradial approach.

Watch: Results of a Stepped-Wedge Trial of Expert-Coaching to Increase Implementation of the Transradial Approach in Cardiac Catheterizations

Find the PDF handout and transcript for Results of a Stepped-Wedge Trial of Expert-Coaching to Increase Implementation of the Transradial Approach in Cardiac Catheterizations