Process evaluation of the Data-driven Quality Improvement in Primary Care (DQIP) trial: case study evaluation of adoption and maintenance of a complex intervention to reduce high-risk primary care prescribing

Abstract

ObjectiveTo explore how different practices responded to the Data-driven Quality Improvement in Primary Care (DQIP) intervention in terms of their adoption of the work, reorganisation to deliver the intended change in care to patients, and whether implementation was sustained over time.DesignMixed-methods parallel process evaluation of a cluster trial, reporting the comparative case study of purposively selected practices.SettingTen (30%) primary care practices participating in the trial from Scotland, UK.ResultsFour practices were sampled because they had large rapid reductions in targeted prescribing. They all had internal agreement that the topic mattered, made early plans to implement including assigning responsibility for work and regularly evaluated progress. However, how they internally organised the work varied. Six practices were sampled because they had initial implementation failure. Implementation failure occurred at different stages depending on practice context, including internal disagreement about whether the work was worthwhile, and intention but lack of capacity to implement or sustain implementation due to unfilled posts or sickness. Practice context was not fixed, and most practices with initial failed implementation adapted to deliver at least some elements. All interviewed participants valued the intervention because it was an innovative way to address on an important aspect of safety (although one of the non-interviewed general practitioners in one practice disagreed with this). Participants felt that reviewing existing prescribing did influence their future initiation of targeted drugs, but raised concerns about sustainability.ConclusionsVariation in implementation and effectiveness was associated with differences in how practices valued, engaged with and sustained the work required. Initial implementation failure varied with practice context, but was not static, with most practices at least partially implementing by the end of the trial. Practices organised their delivery of changed care to patients in ways which suited their context, emphasising the importance of flexibility in any future widespread implementation.Trial registration numberNCT01425502.

Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study

“…Both this network and the dashboard allowed the pharmacists to utilise it for medication safety activities. A similar intervention to improve prescribing safety in primary care, which provided electronic feedback but did not involve pharmacists, found variations in implementation and differences in practice engagement, and that collective engagement within practices, particularly from clinicians, led to more successful implementation [44]. This variation might also be explained in that unlike the previous PINCER trial [11,16] pharmacists in the SMASH intervention stayed with the practices beyond a three-month intervention period.…”

Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed-methods process evaluation

“…This distinction matters because it is important to avoid discarding a potentially effective intervention that was poorly implemented 10 29 30. Implementation difficulties and deficiencies are not infrequently identified in effectiveness evaluations of complex healthcare delivery interventions31–34 but are not always elucidated 20 35. In this study, we found evidence of a degree of implementation failure and, in addition to identifying poorly implemented components, we have considered reasons for poor implementation and whether they are modifiable.…”

Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care

“…Studies of earlier interventions to improve prescribing in primary care have reported variations in engagement. [ 39 , 40 ] and have seen differences in roles with some health professionals utilising technology and others rejecting it. [ 44 ] In the present study there were positive outcomes from the differences in roles since the intervention allowed pharmacists to demonstrate their professional skills through the use of the system and develop the role of clinical pharmacy in general practice.…”

“…Normalization Process Theory (NPT) [ 35 – 38 ] can highlight how an intervention is integrated and adopted into routine practice. NPT has previously been used to evaluate prescribing safety interventions in primary care [ 39 – 40 ], and has utility in examining how individuals and groups understand the intervention through processes of sense-making and how they work to enable the intervention to happen. [ 35 – 38 ] Interventions become part of everyday practice only through the work that people, individually or in groups, undertake.…”