Contributions to the literature
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We drew upon the Theoretical Domains Framework (TDF) and Normalisation Process Theory (NPT) in a longitudinal study to explain the variable success of an adaptable implementation package promoting evidence-based primary care.
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The package worked best when it was sufficiently distinct from but could be integrated within existing organisational routines, with clear benefits for patients. It failed when delivery was delayed and professionals could not observe any improvement resulting from their efforts.
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This study demonstrates the value of integrating psychological and sociological perspectives to design implementation strategies. TDF enabled mapping of the implementation behaviours to attend to, and NPT generated an understanding of how these dynamically interwove with work allocation and negotiation.
Background
Clinical indicators | Description |
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Risky prescribing | Proportion of patients meeting at least one of nine indicators of high-risk NSAID and anti-platelet prescribing: prescription of a traditional oral NSAID or low-dose aspirin in patients with a history of peptic ulceration without co-prescription of gastro-protection; traditional oral NSAID in patients aged 75 years or over without co-prescription of gastro-protection; traditional oral NSAID and aspirin in patients aged 65 years or over without co-prescription of gastro-protection; aspirin and clopidogrel in patients aged 65 years or over without co-prescription of gastro-protection; warfarin and traditional oral NSAID; warfarin and low-dose aspirin or clopidogrel without co-prescription of gastro-protection; oral NSAID in patients with heart failure; oral NSAID in patients prescribed both a diuretic and an angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB); oral NSAID in patients with chronic kidney disease (CKD). |
Diabetes | Proportion of patients with type 2 diabetes achieving all three treatment targets: BP below 140/80 mmHg (or 130/80 mmHg if kidney, eye or cerebrovascular damage); HbA1c value below or equal to 59 mmol/mol; cholesterol level below or equal to 5.0 mmol/l |
Blood pressure | Proportion of patients achieving the lowest appropriate BP target: under 140/90 mmHg if aged under 80 years with hypertension, coronary heart disease, peripheral arterial disease, a history of stroke or transient ischemic attack, or a 10 year cardiovascular disease risk of 20% or higher; under 150/90 mmHg if aged 80 years and over with hypertension; under 140/80 mmHg if aged under 80 years with diabetes, under 130/80 mmHg if complications of diabetes or aged under 80 years with chronic kidney disease and proteinuria. |
Anticoagulation | Combined proportion of men with AF and a CHA2DS2-VASc score of 1 and women with a CHA2DS2-VASc score of 2 or above prescribed anticoagulation therapy. |
Audit and feedback | Educational outreach (supplemented by audit and feedback) | Computerised prompts and paper-based reminders | |
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Materials and training | Practice-specific quarterly audit reports Each report contained a comparison of the practices’ behaviour or outcomes in relation to the other participating practices within their locality (i.e. their Clinical Commissioning Group responsible for commissioning services) and all participating practices across West Yorkshire to reflect on progress and to prompt the need for change. Information on clinical recommendations and potential change strategies were provided. Consequences of inaction were described. Practices were encouraged to set goals based on graded tasks (based on the number of clinical recommendations and number of patients to be targeted within each recommendation) and use an action planning template to detail who would do what; in what circumstances; and how and when the achievement would be reviewed. Subsequent reports included potential actions identified during outreach sessions. Computerised searches Clinical Information System (CIS) searches were available to systematically identify all patients whose care should be reviewed and facilitate repeat searching.
Short and longer significant event audit (SEA) templates
Short and longer forms were developed for risky prescribing and anticoagulation for AF indicators to facilitate root cause analyses and action planning from harmful events or near misses. | We commissioned for and recruited experienced Pharmacist facilitators who received 2 days training. Outreach sessions aimed to increase motivation, prompt individual and group reflection, increase confidence and intention to act. For each outreach visit, a practice-specific outreach pack was developed containing: the most recent (and all previous) audit report(s); a session outline; an action plan template that included space for noting current performance, setting a target, identifying who will do what and review date; and templates for assessing costs and benefits. | For risky prescribing nine computerised prompts were developed to be triggered within the consultation and during repeat prescribing on the basis of a clinical code algorithm for age/diagnosis/drug and duration. When triggered a brief message notified that the patient was at risk and presented one sentence of evidence-based risk (e.g. “This patient has CKD. NSAID use accounts for an estimated 15% of all cases of acute renal failure and 36% of drug-induced cases”). A one-click justification was required (e.g. continue with risk, add medication, or stop medication). Two prompts were developed for anticoagulation for AF but could not be made available within the study timelines. Patient-directed checklists Paper-based reminders in the form of laminated information sheets were created to convey key clinical information (blood pressure, risky prescribing and anticoagulation for AF). Pens and post-it notes were sent to all practices with a topic specific reminder to prompt behaviour. |
Supportive activities | None. | Pharmacist training included a one-day face-to-face meeting with intervention developers focussing on goal setting, action planning, clinical barriers, and persuasive communication. This was followed by a half day of independent study using a folder of supporting documentation relevant to each clinical priority. The first outreach meeting of each facilitator was observed by an experienced facilitator and feedback was given. | None. |
Intervention provider | Reports, searches and templates were created by the research team. | Professional outreach education company. | Reminders were created. |
Mode of delivery | Reports were sent by post and e-mail. Practices were sent invitations to use computerised searches from a task from within their clinical information system. An email was sent from the ASPIRE team to the practice manager and colleagues introducing SEA templates. | Face-to-face sessions were offered to practices. | Practices were sent invitations to use computerised prompts from a task within their clinical information system. An email was also sent from the ASPIRE team to the practice manager and colleagues alerting them to option to accept the prompts into their CIS. |
Schedule and intensity | Quarterly feedback reports. Practices were offered access to searches and SEA templates at the beginning of the study and reminded of their availability via quarterly feedback reports. | Practices were offered an initial 30-min session from April 2016. All practice staff involved in identifying/reviewing appropriate patients were invited to attend. A key clinical contact was identified to support practice engagement. Initial visits focussed on practice achievement data (from audit reports), identifying models of good practice, addressing barriers to change and creating an action plan to facilitate and review the change. Two days of pharmacist provision was offered to support patient identification and review. An additional follow-up visit was offered from 6 months to review action plan progress and support the practice to create more challenging or attainable plans. | Practices were offered access to prompts at the beginning of the study and reminded of their availability via quarterly feedback reports. Practices were offered access to checklists at the beginning of the study and reminded of their availability via quarterly feedback reports. Post-it notes and pens were sent to all practices. |
Tailoring | Searches could be tailored by practices, allowing them to identify patients relevant to all or individual recommendations, or adjust target values to select specific groups of patients. | Session content could be modified to practice requirements. | Prompts could be copied and modified to practice requirements. |
Modifications | None. |
Process evaluation aim and rationale
Methods
Study design and participants
Practice | Identifier | Indicator | Geographical area | Approximate list size |
1 | River | diabetes | Village | 9000 |
2 | Dale | diabetes | City suburb | 10,000 |
3 | Lake | blood pressure | Town | 10,000 |
4 | Hill | blood pressure | City suburb | 5500 |
5 | Valley | anticoagulation | Town | 8500 |
6 | Flower | anticoagulation | City suburb | 15,000 |
7 | Treetop | risky prescribing | City suburb | 4500 |
8 | Brook | risky prescribing | Inner city | 23,500 |
Data collection
Intervention component and delivery mechanism | Sources of fidelity data | Receipt and enactment summary |
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Audit and Feedback | ||
Audit and Feedback reports Delivery: reports were sent by post and email every 3 months and taken to outreach meetings Computerised searches Delivery: organisation group on SystmOne - Practices were sent an email inviting them to join the organisation group to access the searches at any desired time. Alternately used as part of additional support from outreach facilitators Significant Event Audit Forms (for anticoagulation and risky prescribing practices only) Delivery: post and email with reports, and at outreach visits | All practices: Emails were tagged with “delivery” and “read” acknowledgement requests Fidelity survey asked staff to indicate if they received and read forms, and discussed them in their teams Outreach facilitators checked whether audit and feedback forms had been received (and recorded on structured logs) Process evaluation practices only: Researcher noted receipt and awareness of audit and feedback forms, observing where they were seen in practices and exploring practice staff views on the reports in one to one conversation and post-trial group feedback All practices: Computer system tracked whether or not the practices joined the organisational group and downloaded the searches. Outreach facilitators logged use of searches as part of additional support. Fidelity survey asked practices whether they were aware of and used the searches Process evaluation practices: researcher observed use of searches and spoke to practices in post-trial group feedback about the usefulness of searches All practices: Delivery tracked when delivered with audit reports or outreach visits (by outreach facilitators) Process evaluation practices only: researcher observed practices and asked practice staff about awareness and engagement with significant event audit forms. | All practices received reports, as tracked by email delivery and fidelity survey data Process evaluation noted variation in how reports were shared and used within practices (e.g. practice managers not sharing reports widely; only some practices discussing reports at meeting). 126 practices (87.5%) joined the organisational group and therefore could access searches. In the fidelity survey, 75% of trial and process evaluation practices stated they had used the searches. Receipt not specifically tracked in the trial practices, beyond delivery of reports and outreach visit. Searches were made use of in some process evaluation practices (for risky prescribing and anti-coagulation; infrequently for blood pressure and diabetes) In the relevant four process evaluation practices, there was evidence of receipt in one practice but no evidence of receipt or use in the others |
Educational outreach meetings and additional support Delivery: personal visit to practice by outreach facilitator; offer made by phone and on each feedback report Maximum of two educational outreach visits were offered to each practice | All practices: Outreach facilitators completed structured logs recording who attended the training and their job roles. They also recorded which practices took up offer of additional support. Fidelity survey asked practices if they took up the offer of outreach support. Process evaluation practices only: Researcher noted receipt and awareness of outreach support, and asked staff about their engagement and the value of outreach meetings and support in one to one conversations and post-trial group feedback | Sixty-seven (47%) trial practices and seven (87.5%) of process evaluation practices received one outreach meeting. Reasons given for not taking up outreach offer: Trial practices declined because they were not interested, too busy or felt it was not needed. One anticoagulation process evaluation practice declined because they felt confident to do the work without outreach meeting. Additional support was taken up by 16 (24%) trial practices and five process evaluation practices. Most support was delivered remotely in the form of running searches, reviewing patient notes, and creating recommendations for management. Awareness of additional support was low in process evaluation practices (usually 1-2 staff members being aware of it). Eight (5.6%) trial practices and three process evaluation practices received a second visit, another requested a visit but this could not be accommodated before trial end. Significant delays noted in delivering outreach visits to practices. |
Reminders | ||
Computerised prompts (available for risky prescribing only) Delivery: organisation group on SystmOne - Practices were sent an email inviting them to join the organisation group to access the prompts at any desired time. | All practices: Computer system tracked whether or not the practice downloaded the prompts Fidelity survey asked practices if they used the prompts Process evaluation only: researcher asked staff about their awareness and engagement with the prompts | Eight (32%) trial practices and both process evaluation practices downloaded the risky prescribing protocol Evidence from process evaluation practices that the prompts were considered useful by one practice as they enabled greater involvement of staff typically not involved in risky prescribing decisions. |
Data management and analysis
Results
Observation, final practice meeting, Flower (anticoagulation)
Observation, Valley (anticoagulation)
GP lead, interview, Treetop (risky prescribing)
The feedback reports enabled change by targeting gaps in knowledge around risky prescribing and anticoagulation (TDF knowledge); data illustrating the importance of the topic stimulated a belief that the work was valuable (TDF beliefs about consequences); the small numbers needed to treat enabled a sense of the work as achievable (TDF beliefs about capabilities and environmental context and resources). The intervention met a perceived need and outlined clear individual and communal expectations (NPT communal and individual specification) without replicating current practices (NPT differentiation). The anticoagulation reports traded on appropriate expertise to encourage practices (TDF social influence); in risky prescribing, comparison with other practices stimulated competitiveness (TDF social influence). Those involved attending outreach meetings and reviewing reports were appropriate in terms of clear roles and skills to do the work (TDF social and professional roles and skills). This enabled staff to outline work needed quickly and efficiently, targeted at the right people (NPT initiation, enrolment, and legitimation). Staff worked together and had clear ideas of who did what (TDF social and professional roles; NPT interactional and skill-set workability). Risky prescribing practices that repeated the searches saw the impact of their work (NPT systematisation). As the trial went on, positive feedback on achievement encouraged continued engagement (TDF motivation and emotions). Discussing this feedback enabled continued work (NPT activation), as well as reinforced a sense of how feasible and useful the work was in practice (NPT individual and communal appraisal). |
Observation, educational outreach, Lake (blood pressure)
Observation, GP interview, Hill (blood Pressure)
Observation, final practice meeting, River (diabetes)
Observation, final practice meeting, River (diabetes)
Lead GP, interview, Lake (blood pressure)
It was felt that the practices knew about the topics and already worked hard to achieve outcomes (TDF knowledge and beliefs about capabilities). It was felt little more could be achieved (TDF beliefs about consequences, motivation & emotion). The intervention did not seem to add value or seem different to the practice’s existing work (NPT differentiation) and staff felt it was more or less important to work to the specified intervention targets (NPT communal and individual specification). Practices felt they did not have the resources or the incentive to change systems and processes (TDF environmental context and resources and motivation; NPT coherence). Outreach meetings tended to involve large numbers of staff with varied interests and desire to engage in work (TDF social and professional roles and skills). Levels of participation in work around the intervention varied (NPT cognitive participation: initiation and enrolment), and there was little sense of the intervention being integrated into staff routines or influencing the allocation of resources (NPT collective action: relational and contextual integration) due to how staff perceived the intervention as irrelevant to their role (TDF social and professional roles) and unlikely to impact on patient outcomes without negatively affecting patient rapport (TDF beliefs about consequences). |
Lead GP, interview, Dale (diabetes)
Observation, final practice meeting, River (diabetes)
Interview, Practice manager, Dale (diabetes)
For diabetes and blood pressure practices, the intervention failed to differentiate itself from routine work (NPT differentiation), and practice staff perceived themselves as already doing this work (TDF social and professional roles), lacking resources or capacity to do any more work (TDF environmental context and resources, beliefs about capabilities), and unlikely to achieve anything more by engaging with the intervention (NPT communal specification; TDF beliefs about consequences). Some staff perceived its value (NPT individual specification) but were unable to gain traction with other team members (NPT cognitive participation: enrolment and legitimation). Delays in delivery of outreach and outreach support had the unintended consequence of delaying practice participation and access to trial resources (TDF social influences and environmental context and resources), reducing the likelihood that staff would have time to adopt changes in their work (NPT collective action: contextual integration) or enrol in the work (NPT cognitive participation: enrolment). Feedback reports had the unintended consequence of de-motivating staff as they failed to achieve change on the more ambitious indicators (TDF motivation and emotion) and staff reacted by reducing visibility of the intervention (TDF memory) or believing the intervention to be ineffective or not worth engaging in (TDF beliefs about consequences; NPT collective action: relational integration). |
Discussion
Study limitations
Implications for practice and research
Stage | Lesson |
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Selecting indicators | Consider fit with professional values, patient benefit and practice goals to enable a clear understanding of the need for something to be done differently and that improvement is possible Consider workload of reviewing patients near to targets (e.g. impact of stringent targets on patient preferences and rapport) and how this fits with achievement Ensure outcome measures are sensitive to efforts to improve achievement to enable learning from working to achieve change Limit the number of indicators and specify clear corrective actions or behaviours that will have impact on achievement Make visible individual contributions towards changing team-based behaviours and enable individuals to be accountable to themselves and their team |
When developing intervention components | |
Audit and feedback | Identify a named lead to coordinate the overall plan and individual actions Facilitate reach to those who are able to act to improve performance and suggest that feedback is made visible in the practice and at practice meetings Make clear relevance to non-clinicians Focus on feedback for learning in addition to feedback on performance (i.e. what could be done differently in addition to feedback on gap between actual and desired performance to support underachievers) Frame behaviour to showcase benefit of additional or modified ways of working (e.g. reduce unwanted actions (e.g. reduce risky prescribing or reduce strokes) as opposed to increase desired behaviours (e.g. increase prescription of anticoagulation)) Action plans that suggest specific and feasible actions could minimise cognitive load and overcome habitual patterns of working Consider reporting timeframe in relation to work to be undertaken. Estimate timeframes required for actions on action plans and time feedback accordingly Repeated negative feedback may be dispiriting and decrease ownership |
Educational outreach | Provide a time to review audit feedback and conduct patient-identifiable searches before meeting face-to-face to further explore barriers and goal setting Enrol all potentially relevant staff (e.g. administrative, managerial and clinical) as early as possible to create a sense of ownership and maximise time for improvement Create an open discussion of problems, how individuals work and ways to overcome challenges Ensure that the facilitator is seen as credible |
Reminders | Patient identifiable searches may reduce burden and enable practices to develop a continuous feedback loops to track and maintain improvements Ensure that searches and computerised prompts can be easily adapted to focus on practice targets for achievement Computerised prompts may be applicable to both clinical and administrative staff involved in repeat prescribing |
When delivering interventions | Establish commitment, rapport and mobilise resources prior to intervention delivery (e.g. time commitment, access to identifiable audit data) to increase awareness of intervention package Identify a practice lead who can empower participation and manage competing priorities Establish a team including management, clinicians and administrators to reinforce collective action Encourage rapid actions in intermediate process and outcomes to make progress visible and increase internal motivation to continuously improve Consider opportunities for social exchange of success stories of what others are doing |
When evaluating implementation components | Enable interactive communication between intervention developers and practices to support tailoring and adaptation of interventions to context Pilot test delivery, receipt and engagement as informed by NPT and TDF constructs before evaluating at scale |