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Explaining variable effects of an adaptable implementation package to promote evidence-based practice in primary care : a longitudinal process evaluation

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Glidewell_2022_IS_Explaining_variable_effects_CC.pdf (3.429Mb)
Date
27/01/2022
Author
ASPIRE programme team
Glidewell, Liz
Hunter, Cheryl
Ward, Vicky
McEachan, Rosemary R. C.
Lawton, Rebecca
Willis, Thomas A.
Hartley, Suzanne
Collinson, Michelle
Holland, Michael
Farrin, Amanda J.
Foy, Robbie
Keywords
Tailored intervention
Adaptable implementation package
Theoretical Domains Framework
Normalization Process Theory
Process evaluation
Audit and feedback
Educational outreach
Computerised prompts
Clinical reminders
Primary care
Fidelity
H Social Sciences (General)
E-DAS
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Abstract
Background Implementing evidence-based recommendations is challenging in UK primary care, especially given system pressures and multiple guideline recommendations competing for attention. Implementation packages that can be adapted and hence applied to target multiple guideline recommendations could offer efficiencies for recommendations with common barriers to achievement. We developed and evaluated a package of evidence-based interventions (audit and feedback, educational outreach and reminders) incorporating behaviour change techniques to target common barriers, in two pragmatic trials for four “high impact” indicators: risky prescribing; diabetes control; blood pressure control; and anticoagulation in atrial fibrillation. We observed a significant, cost-effective reduction in risky prescribing but there was insufficient evidence of effect on the other outcomes. We explored the impact of the implementation package on both social processes (Normalisation Process Theory; NPT) and hypothesised determinants of behaviour (Theoretical Domains Framework; TDF). Methods We conducted a prospective multi-method process evaluation. Observational, administrative and interview data collection and analyses in eight primary care practices were guided by NPT and TDF. Survey data from trial and process evaluation practices explored fidelity. Results We observed three main patterns of variation in how practices responded to the implementation package. First, in integration and achievement, the package “worked” when it was considered distinctive and feasible. Timely feedback directed at specific behaviours enabled continuous goal setting, action and review, which reinforced motivation and collective action. Second, impacts on team-based determinants were limited, particularly when the complexity of clinical actions impeded progress. Third, there were delivery delays and unintended consequences. Delays in scheduling outreach further reduced ownership and time for improvement. Repeated stagnant or declining feedback that did not reflect effort undermined engagement. Conclusions Variable integration within practice routines and organisation of care, variable impacts on behavioural determinants, and delays in delivery and unintended consequences help explain the partial success of an adaptable package in primary care.
Citation
ASPIRE programme team , Glidewell , L , Hunter , C , Ward , V , McEachan , R R C , Lawton , R , Willis , T A , Hartley , S , Collinson , M , Holland , M , Farrin , A J & Foy , R 2022 , ' Explaining variable effects of an adaptable implementation package to promote evidence-based practice in primary care : a longitudinal process evaluation ' , Implementation Science , vol. 17 , 9 . https://doi.org/10.1186/s13012-021-01166-4
Publication
Implementation Science
Status
Peer reviewed
DOI
https://doi.org/10.1186/s13012-021-01166-4
ISSN
1748-5908
Type
Journal article
Rights
This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Description
This study is funded by the National Institute for Health Research (NIHR) [Programme Grants for Applied Research (Grant Reference Number RP-PG-1209-10040)] (https://www.nihr.ac.uk/).
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  • University of St Andrews Research
URI
http://hdl.handle.net/10023/24781

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