Process evaluation of the data-driven quality improvement in primary care (DQIP) trial: active and less active ingredients of a multi-component complex intervention to reduce high-risk primary care prescribing

Abstract

BackgroundTwo to 4% of emergency hospital admissions are caused by preventable adverse drug events. The estimated costs of such avoidable admissions in England were £530 million in 2015. The data-driven quality improvement in primary care (DQIP) intervention was designed to prompt review of patients vulnerable from currently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelets and was found to be effective at reducing this prescribing. A process evaluation was conducted parallel to the trial, and this paper reports the analysis which aimed to explore response to the intervention delivered to clusters in relation to participants’ perceptions about which intervention elements were active in changing their practice.MethodsData generation was by in-depth interview with key staff exploring participant’s perceptions of the intervention components. Analysis was iterative using the framework technique and drawing on normalisation process theory.ResultsAll the primary components of the intervention were perceived as active, but at different stages of implementation: financial incentives primarily supported recruitment; education motivated the GPs to initiate implementation; the informatics tool facilitated sustained implementation. Participants perceived the primary components as interdependent. Intervention subcomponents also varied in whether and when they were active. For example, run charts providing feedback of change in prescribing over time were ignored in the informatics tool, but were motivating in some practices in the regular e-mailed newsletter. The high-risk NSAID and anti-platelet prescribing targeted was accepted as important by all interviewees, and this shared understanding was a key wider context underlying intervention effectiveness.ConclusionsThis was a novel use of process evaluation data which examined whether and how the individual intervention components were effective from the perspective of the professionals delivering changed care to patients. These findings are important for reproducibility and roll-out of the intervention.Trial registrationClinicalTrials.gov, NCT01425502.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0531-2) contains supplementary material, which is available to authorized users.

Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review

“…Quantitative and document analysis designs were utilised once each. Among the 25 articles using qualitative methods only, ten used semi-structured interviews [32,39,44,45,47,49,50,55,57,58]; one utilised focus groups [60]; seven involved a combination of semistructured interviews and focus groups [34-38, 52, 56]; six were ethnographic studies [33,46,48,51,53,61]; and one used in-depth interviews [41]. The mixedmethods studies used varying combinations of semistructured interviews, focus groups, survey data, patient data, and narrative and systematic reviews of the literature [31,40,42,43].…”

“…One such example is Browne et al, who utilised NPT to focus attention on patients and carers' work of managing a terminal condition and to characterise healthcare professionals' responses to patients' palliative care needs [36]. The remaining two articles applied the construct of Coherence only [41,52].…”

“…Identification of where the intervention addressed potential implementation issues [31,37,41,49,50,53].…”

“…Three articles [31,41,43] utilised all 16 sub-constructs of NPT. Band et al applied all of the constructs and subconstructs for the analysis of behaviours at the individual and organisational levels to identify appropriate behavioural change techniques in the development of an intervention addressing the management of hypertension [31].…”

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

“…The qualitative element consisted of case studies in 10 of the 33 participating practices. Practice staff perceptions of the importance of different intervention components and when they had an effect are reported separately 19. The analysis reported here examines how practices adopted, implemented and maintained the intervention.…”