Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study
ABSTRACT Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts. Educational outreach into practices, alongside other measures, such as audit and feedback, have the potential to enable GP prescribing to become more evidence based. High GP prescribing costs are associated with GPs who see drug company representatives; tend to end consultations with prescriptions; and 'try out' new drugs on an 'ad hoc basis' and use this as evidence of the drug's effect. An educational intervention called 'reflective practice' was developed to meet these and other educational needs. The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice.
The study investigated the following: (i) Is it feasible for GPs to attend the sessions included in the educational intervention? (ii) Is the intervention acceptable to the participants and the session facilitators? (iii) What are the barriers to the group educational processes, and how can these be overcome?
Four practices were recruited in South West England, all of them experiencing problems with prescribing appropriateness and cost. Reflective practice sessions (including a video-taped scenario) were run in each of these practices and qualitative methods were used to explore the complex attitudes and behaviour of the participants. A researcher observed and audio-taped sessions in each practice. At the end of the programme, a sample of doctors and all the facilitators were interviewed about their experiences. The recorded data were transcribed and analysed using standard qualitative methods.
The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions. Elsewhere, doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality. Facilitators came from a broad range of professional backgrounds. While knowledge of prescribed drug management issues was important, the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory. The video-taped scenario was found to be useful to set the scene for the discussion. Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion. Reaching a consensus on management of common conditions was sometimes difficult, partly because the use of the term 'best buy' implies economic pressures, rather than benefits to patients, and partly because of the value with which GPs regard the concept of clinical autonomy. 'Reflective Practice' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence.
The study indicates the importance of preparing the practice adequately, including providing protected time for all GPs to attend the educational intervention. Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness. Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized. We have also identified the skill profile of the facilitator role. Our study indicates a need for a clearer understanding of GPs' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment. The intervention is now ripe for further development, perhaps by integrating it with other interventions to change professional behaviour. The improved intervention should then be evaluated in a randomized controlled trial.
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ABSTRACT: Research has shown that a number of patients, with a variety of diagnoses, are admitted to hospital when it is not essential and can remain in hospital unnecessarily. To date, research in this area has been primarily quantitative. The purpose of this study was to explore the perceived causes of inappropriate or prolonged lengths of stay and focuses on a specific population (i.e., patients with long term neurological conditions). We also wanted to identify interventions which might avoid admission or expedite discharge as periods of hospitalisation pose particular risks for this group. Two focus groups were conducted with a convenience sample of eight primary and secondary care clinicians working in the Derbyshire area. Data were analysed using a thematic content approach. The participants identified a number of key causes of inappropriate admissions and lengths of stay, including: the limited capacity of health and social care resources; poor communication between primary and secondary care clinicians and the cautiousness of clinicians who manage patients in community settings. The participants also suggested a number of strategies that may prevent inappropriate admissions or reduce length of stay (LoS), including: the introduction of new sub-acute care facilities; the introduction of auxiliary nurses to support specialist nursing staff and patient held summaries of specialist consultations. Clinicians in both the secondary and primary care sectors acknowledged that some admissions were unnecessary and some patients remain in hospital for a prolonged period. These events were attributed to problems with the current capacity or structuring of services. It was noted, for example, that there is a shortage of appropriate therapeutic services and that the distribution of beds between community and sub-acute care should be reviewed.BMC Health Services Research 02/2009; 9:44. DOI:10.1186/1472-6963-9-44 · 1.66 Impact Factor
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ABSTRACT: Irrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the "OTC SOCIOMED", conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region. This feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design was employed. Quantitative and qualitative data were collected at pre- and post-intervention phases. The primary outcome of this feasibility pilot intervention was to reduce GPs' intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs. Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale. Evidence from this intervention will help determine the most relevant variables and estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.BMC Family Practice 02/2014; 15(1):34. DOI:10.1186/1471-2296-15-34 · 1.74 Impact Factor
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ABSTRACT: The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention. The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups. We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program. The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care.Trial registration: ClinicalTrials.gov: NCT01297075.BMC Family Practice 04/2014; 15(1):65. DOI:10.1186/1471-2296-15-65 · 1.74 Impact Factor