Key result
Adaptable implementation package improves risky prescribing routines but falters when workflows require complex coordination.
Why the study?
How do social processes, behavioural determinants, and fidelity of delivery explain the variable effectiveness of an adaptable implementation package across four clinical indicators in UK primary care practices?
How do social processes, behavioural determinants, and fidelity of delivery explain the variable effectiveness of an adaptable implementation package across four clinical indicators in UK primary care practices?
Answers are grounded in this paper and cite their sources.
This longitudinal process evaluation demonstrates that adaptable primary care implementation packages succeed when targeting distinctive, feasible actions for small patient cohorts (such as risky prescribing), but fail to improve complex team-dependent targets (such as blood pressure or diabetes control) when hindered by outreach delays and demotivating feedback.
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.
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Glidewell et al. (2022) studied Implementation of evidence-based primary care recommendations across four high-impact indicators: risky prescribing, type 2 diabetes control, blood pressure control, and anticoagulation in atrial fibrillation (n=152). Adaptable implementation package (audit and feedback, educational outreach, and computerised prompts and paper-based reminders) vs. Active intervention targeting an alternative clinical indicator within a balanced incomplete block design was evaluated on Fidelity (delivery, receipt, and enactment), integration within practice routines (Normalisation Process Theory), and impact on behavioural determinants (Theoretical Domains Framework). The adaptable implementation package achieved integration for risky prescribing when considered distinctive and feasible, whereas complex team actions and outreach delays impeded other indicators.
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