Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation

C M Hespe,K Giskes,D Peiris,M F Harris

doi:10.1186/s12913-021-07310-6

Abstract

BackgroundThere are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice. Quality-improvement (QI) initiatives aim to reduce these gaps. This study evaluated a QI program (QPulse) that focussed on CVD assessment and management.MethodsThis mixed-methods study explored the implementation of guidelines and adoption of a QI program with a CVD risk-reduction intervention in 34 general practices. CVD screening and management were measured pre- and post-intervention. Qualitative analyses examined participants’ Plan-Do-Study-Act (PDSA) goals and in-depth interviews with practice stakeholders focussed on barriers and enablers to the program and were analysed thematically using Normalisation Process Theory (NPT).ResultsPre- and post-intervention data were available from 15 practices (n = 19,562 and n = 20,249, respectively) and in-depth interviews from seven practices. At baseline, 45.0% of patients had their BMI measured and 15.6% had their waist circumference recorded in the past 2 years and blood pressure, lipids and smoking status were measured in 72.5, 61.5 and 65.3% of patients, respectively. Most high-risk patients (57.5%) were not prescribed risk-reducing medications. After the intervention there were no changes in the documentation and prevalence of risk factors, attainment of BP and lipid targets or prescription of CVD risk-reducing medications. However, there was variation in performance across practices with some showing isolated improvements, such as recording waist circumference (0.7-32.2% pre-intervention to 18.5-69.8% post-intervention), BMI and smoking assessment. Challenges to the program included: lack of time, need for technical support, a perceived lack of value for quality improvement work, difficulty disseminating knowledge across the practice team, tensions between the team and clinical staff and a part-time workforce.ConclusionThe barriers associated with this QI program was considerable in Australian GP practices. Findings highlighted they were not able to effectively operationalise the intervention due to numerous factors, ranging from lack of internal capacity and leadership to competing demands and insufficient external support.Trial registrationAustralian New Zealand Clinical Trials Reference Number (ACTRN12615000108516), registered 06/02/2015.

Highlights

There are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice
All Primary Health Network (PHN) staff working on QPulse received standardised training from the research group in the CVD risk-reduction intervention, the QI program and the implementation processes
After the program there were no significant changes in the assessment of CVD risk factors, the achievement of blood pressure (BP) and blood lipid targets or the prescription of risk-reducing medications

Summary

Introduction

There are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice. Cardiovascular diseases (CVD) are the leading cause of death worldwide, despite major declines in morbidity and mortality over the last 40 years [1]. CVD burden can be reduced through risk-factor modification [4]. Around two-thirds of Australians have three or more modifiable risk factors such as tobacco smoking, high blood pressure (BP) or cholesterol, physical inactivity, poor nutrition, or overweight/obesity [1, 5]. In 2012, the National Vascular Disease Prevention Alliance launched Australia’s first absolute risk-based management guideline bringing together several guidelines into a single cohesive approach [5]

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