Abstract
BackgroundA computerised, multifaceted quality improvement (QI) intervention for cardiovascular disease (CVD) management in Australian primary healthcare was evaluated in a cluster randomised controlled trial. The intervention was associated with improved CVD risk factor screening but there was no improvement in prescribing rates of guideline-recommended medicines. The aim of this study was to conduct a process evaluation to identify and explain the underlying mechanisms by which the intervention did and did not have an impact.Methods/designNormalisation process theory (NPT) was used to understand factors that supported or constrained normalisation of the intervention into routine practice. A case study design was used in which six of the 30 participating intervention sites were purposively sampled to obtain a mix of size, governance, structure and performance. Multiple data sources were drawn on including trial outcome data, surveys of job satisfaction and team climate (68 staff) and in-depth interviews (19 staff). Data were primarily analysed within cases and compared with quantitative findings in other trial intervention and usual care sites.ResultsWe found a complex interaction between implementation processes and several contextual factors affecting uptake of the intervention. There was no clear association between team climate, job satisfaction and intervention outcomes. There were four spheres of influence that appeared to enhance or detract from normalisation of the intervention: organisational mission and history (e.g. strategic investment to promote a QI culture enhanced cognitive participation), leadership (e.g. ability to energise or demotivate others influenced coherence), team environment (e.g. synergistic activities of team members with different skill sets influenced collective action) and technical integrity of the intervention (e.g. tools that slowed computer systems limited reflective action).DiscussionUse of NPT helped explain how certain contextual factors influence the work that is done by individuals and teams when implementing a novel intervention. Although these factors do not necessarily distil into a recipe for successful uptake, they may assist system planners, intervention developers, and health professionals to better understand the trajectory that primary health care services may take when developing and engaging with QI interventions.Trial registrationACTRN 12611000478910. Registered 08 May 2011.
Highlights
A computerised, multifaceted quality improvement (QI) intervention for cardiovascular disease (CVD) management in Australian primary healthcare was evaluated in a cluster randomised controlled trial
In the area of cardiovascular disease (CVD) risk management, around 50% of adults attending primary healthcare are adequately screened for CVD risk and only around 40% of those identified at high risk are prescribed recommended medications [1,2,3]
Development of the intervention Drawing on the above literature, we developed a multifaceted QI intervention for CVD management in Australian primary healthcare
Summary
A computerised, multifaceted quality improvement (QI) intervention for cardiovascular disease (CVD) management in Australian primary healthcare was evaluated in a cluster randomised controlled trial. In the area of cardiovascular disease (CVD) risk management, around 50% of adults attending primary healthcare are adequately screened for CVD risk and only around 40% of those identified at high risk are prescribed recommended medications [1,2,3] To address these entrenched gaps, the US National Academy of Medicine recommended changing the healthcare environment in four ways: increasing the uptake of evidence in healthcare delivery, leveraging information technology, aligning payment reform with quality improvement and enhancing workforce support [4, 5]. HIT strategies with the strongest evidence base include computerised clinical decision support systems and audit and feedback of performance to providers These have been shown to improve processes of care with a modest impact on healthcare outcomes [13,14,15,16,17]
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