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ISQUA17-1479
ENABLERS OF AND BARRIERS TO CHANGE IN PRIMARY CARE: A PROCESS EVALUATION OF AN ADAPTABLE GUIDELINE IMPLEMENTATION STRATEGY

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Enablers of and barriers to change in primary care: a process evaluation of an adaptable guideline implementation strategy

Cheryl Hunter1, Liz Glidewell2, Tom Willis2, Vicky Ward2, Rosie McEachan3, Rebecca Lawton3,4, Robbie Foy2,on behalf of ASPIRE programme team - Correspondence: [email protected] or [email protected]

Background

•Variation in implementation of guidelines is not fully explained by (measured) patient and practice characteristics
•UK general practices are under pressure on a number of fronts:
•Multiple top-down and bottom-up priorities
•Multiplying demands
•Multiple ‘re-disorganisation

Objectives

Strategy to improve guideline adherence in one of: Diabetes control; Blood pressure control; Anticoagulation in atrial fibrillation; Risky prescribing (esp. around avoiding adverse effects of NSAIDs & anti-platelet drugs)

Process evaluation, aimed to examine:

1.How strategy was received and enacted

2.Whether strategy became embedded into routines or had unintended consequences
 

Implementation Strategy

1.Audit and feedback (quarterly reports and computerized searches)
2.Educational outreach with pharmacist support
3.Clinical prompts and reminders
 

Methods

Sample: 8 general practices in West Yorkshire, 2 practices per clinical indicator

Data collection: Observations, 2 rounds of staff interviews, end of study group interviews, document analysis, fidelity survey

Analysis: Framework approach, using Normalization Process Theory (NPT)

Results - 2 examples

'Dale’ Practice (Diabetes Control – Missed Opportunities)

Competing priorities; poor differentiation & collective action

Lead GP thought they had been more proactive with patients in recent times & more conscious of all three targets as goals. He said they had been working on them anyway

Administrator said that f they had included her from the beginning, she could have given them support, but everyone had thought it was a clinical intervention 

‘Treetop’ Practice (Risky Prescribing – Team Working)

Coherent, shared understanding of work; Clearly defined roles

Lead GP said we realised where we were deficient (…) it’s good to have other people to compare against cos you’re actually working quite a lot in isolation

The GP said everybody knew about it, and all the prescribers knew about it, and everybody got reminded about it

Implications

Targeted guideline made a difference: ‘Control’ guidelines were harder to implement than ‘Prescribing’ ones

Involving whole practice provided extra resources & checks; not all practices interpreted intervention this way

Practices prioritized pre-existing work patterns: staff felt they were already working to capacity & resisted change

Analyzing longitudinal data using NPT enabled us to track implementation as a non-linear dynamic process

Affiliations:

1 Nuffield Department of Primary Care Health Sciences, University of Oxford;

2 Academic Unit of Primary Care, LIHS, University of Leeds; 

3 Bradford Institute for Health Research, Bradford;

4 School of Psychology, University of Leeds

Acknowledgements

This presentation summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research Programme (Grant Reference Number RP-PG-1209-10040).  The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department 

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