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. 2022 Jan 27;17(1):9.
doi: 10.1186/s13012-021-01166-4.

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

Liz Glidewell #  1   2 , Cheryl Hunter #  3   4 , Vicky Ward  3   5 , Rosemary R C McEachan  6 , Rebecca Lawton  6   7 , Thomas A Willis  3 , Suzanne Hartley  8 , Michelle Collinson  8 , Michael Holland  8 , Amanda J Farrin  8 , Robbie Foy  3 ; ASPIRE programme team
Collaborators, Affiliations

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

Liz Glidewell et al. Implement Sci. .

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.

Keywords: Adaptable implementation package; Audit and feedback; Clinical reminders; Computerised prompts; Educational outreach; Fidelity; Normalization Process Theory; Primary care; Process evaluation; Tailored intervention; Theoretical Domains Framework.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Multifaceted adaptable implementation package as planned
Fig. 2
Fig. 2
Comparing and contrasting engagement and predicted achievement in the four packages (categories predicted prior to trial results and confirmed by trial findings)
Fig. 3
Fig. 3
Fidelity of delivery and engagement as intended and observed variations indicated by stop signs
See this image and copyright information in PMC

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