How GPs implement clinical guidelines in everyday clinical practice--a qualitative interview study

Implementation and acceptability of the Caregiver Care Model in general practice: a mixed-method feasibility study

BACKGROUND

Being a caregiver can be demanding. Therefore, we developed the Caregiver Care Model for general practice. The model consists of a mandatory dialogue questionnaire, which is used to identify support needs in caregivers, grief-facilitating questions, and an overview of community-based caregiver initiatives for caregivers in need of support. We aimed to test the implementation and acceptability of the model in general practice.

METHODS

We used a fixed, convergent, mixed-methods approach to test the model in five general practices in the Central Denmark Region among 40 caregivers. Quantitative data included monitoring data collected by health professionals in an online database at inclusion and after each consultation. Qualitative data were derived from five introductory meetings and semi-structured interviews with ten health professionals. The analysis focused on the implementation (delivery and process) and the health professionals' acceptability of the model.

RESULTS

All 40 caregivers participated in the first consultation, and 29 (73%) had two or more consultations. Eight caregivers (20%) were referred to community-based initiatives or a private-practice psychologist. The mandatory dialogue questionnaire was completed by 30 (75%) caregivers prior to the first consultation, and it was rated useful by general practitioners (GPs) and staff in 26 (74%) of encounters. GPs and staff perceived the dialogue questionnaire to be useful to direct the first consultations towards the most relevant issues, whereas the usefulness of the facilitating questions was unclear due to the brief introduction to them. The list of community-based initiatives was considered useful in urban areas, but not in rural areas with long distance to initiatives. Here, support from general practice was needed to promote mental health in caregivers and avoid sick leave.

CONCLUSION

The Caregiver Care Model was in line with core values of general practice and the dialogue questionnaire targeted the consultations on relevant issues for the caregiver. Health professionals provided targeted support, including follow-up consultations and referred a group for community-based initiatives, especially caregivers in urban settings. The findings call for increased focus on caregivers and education of general practitioners and staff to facilitate caregiver reactions in connection with loss and grief.

Follow-up after gestational diabetes: a qualitative study of perspectives from general practices

BACKGROUND

Women whose pregnancies are complicated by gestational diabetes mellitus are approximately eight times more likely to develop type two diabetes. Although regular participation in follow-up screening increases the chance of early detection of diabetes, participation rates are often suboptimal. A better understanding of general practice as a key contextual setting for screening could help inform the development and adoption of, for example, electronic reminder interventions to support women's participation.

AIM

To explore the perspectives of general practitioners and relevant staff members engaged in early detection of diabetes after gestational diabetes in order to identify barriers to and facilitators of follow-up screening.

DESIGN & SETTING

A qualitative interview study undertaken in general practices in the North Denmark Region.

METHOD

Based on a purposive sample strategy, 18 semi-structured interviews of 12 general practitioners and six staff members, who were either nurses or midwives, were analysed using a reflexive thematic analytical approach.

RESULTS

Three main themes were formulated: (1) Challenges of addressing women's risk; (2) Prioritisation of early detection of diabetes; (3) System influence on clinical procedures.

CONCLUSION

Follow-up screening was facilitated by knowledge of guidelines. We found professional collaboration and adaptation support to lead to successful implementation of guidelines in general practice. Supporting GPs and their staff's reflection and discussion of ways to engage in communication and decision-making processes with women is however important, hence it was found to create an important barrier to follow-up screening. Overall, our findings can help inform the future development of interventions to increase uptake.

Reducing unnecessary antibiotic prescription through implementation of a clinical guideline on self-limiting respiratory tract infections

BACKGROUND

Clinical guidelines (CG) are used to reduce variability in practice when the scientific evidence is sparse or when multiple therapies are available. The development and implementation of evidence-based CG is intended to organize and provide the best available evidence to support clinical decision making in order to improve quality of care. Upper respiratory tract infections (URTI) are the leading cause of misuse of antibiotics and a CG may reduce the unnecessary antibiotic prescription.

METHODS

The aim of this quasi-experimental, before-after study was to analyze the short- and long-term effects of the implementation of a CG to decrease the rate of antibiotic prescription in URTI cases in the emergency department of a third level private hospital in Quito, Ecuador. The study included 444 patients with a main diagnosis of URTI. They were distributed in three groups: a baseline cohort 2011 (n = 114), a first post-implementation cohort 2011 (n = 114), and a later post-implementation cohort 2018 (n = 216). The implementation strategy consisted of five key steps: acceptance of the need for implementation of the CG, dissemination of the CG, an educational campaign, constant feedback, and sustainability of the strategy through continuous training.

RESULTS

The results of this study show a 42.90% of antibiotic prescription rate before the CG implementation. After the implementation of the CG, the prescription rate of antibiotics was significantly reduced by 24.5% (42.9% vs 18.4%, p<0.0001) and the appropriate antibiotic prescription rate was significantly increased by 44.2% (22.4% vs 66.6%, p<0.0001) in the first post-implementation cohort 2011. There was not a significant difference in antibiotic prescription rate and appropriate antibiotic prescription rate between two post-implementation cohorts: 18.4% vs 25.9% (p = 0.125) and 66.6% vs 50% (p = 0.191), respectively.

CONCLUSIONS

The implementation of CGs decreases the rate of antibiotic prescription in URTI cases. The results are remarkable after early implementation, but the effect persists over time. The emphasis must shift from guideline development to strategy implementation.

Exploring implementation processes in general practice in a feedback intervention aiming to reduce potentially inappropriate prescribing: a qualitative study among general practitioners

Background

Potentially inappropriate prescribing (PIP) has been linked with adverse health outcomes and increased healthcare costs. Feedback interventions targeting PIP have shown promising results. However, translation from research to everyday practice remains a challenge. With the Normalisation Process Theory (NPT) as overarching framework, we aimed to explore the implementation processes performed by general practices in a real-life, quality improvement intervention using feedback on practice-level prescribing.

Methods

All 376 general practices in the Central Denmark Region received a prescribing feedback intervention targeting selected types of PIP. Six months later, they received an evaluation questionnaire, to which 45% responded. Among 102 practices reporting to have made changes in response to the intervention, we conducted individual, semi-structured interviews with ten GPs. Maximum variation was sought in terms of baseline prescribing status, implementation activities, practice type and geographical location. The interviews were analysed thematically using NPT.

Results

The implementation processes in general practice reflected the four NPT constructs. Key motivators for implementation included the GPs’ professional values and interests, but pragmatic considerations were also of importance (coherence). A collective versus an individual approach to the engagement and planning of the implementation process (cognitive participation) was observed. Similarly, a distinction was evident between practice-level actions involving the entire practice team as opposed to individual-level actions performed by the individual GP (collective action). Several challenges to the implementation processes were identified, including patient influences and competing priorities at multiple levels (reflexive monitoring). Additionally, internal evaluation and normalisation of new practices occurred in varying degrees.

Conclusion

NPT provided a useful framework for understanding implementation processes in general practice. Our results emphasise that clear professional aims and feasible content of interventions are key for GP motivation. This may be ensured through cooperation with GPs’ professional organisation, which may strengthen intervention legitimacy and uptake. Two main implementation strategies were identified: practice-level and GP-level strategies. Intervention developers need to recognise both strategies to deliver intervention content and implementation support that promote sustainable improvements in prescribing practice. Competing demands and patient influences remain important challenges that need to be addressed in future studies to further facilitate the reduction of PIPs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-020-00106-5.

A plea to merge clinical and public health practices: reasons and consequences

BACKGROUND

Revisiting professionalism, both as a medical ideal and educational topic, this paper asks whether, in the rise of artificial intelligence, healthcare commoditisation and environmental challenges, a rationale exists for merging clinical and public health practices. To optimize doctors' impact on community health, clinicians should introduce public health thinking and action into clinical practice, above and beyond controlling nosocomial infections and iatrogenesis. However, in the interest of effectiveness they should do everything possible to personalise care delivery. To solve this paradox, we explore why it is necessary for the boundaries between medicine and public health to be blurred.

MAIN BODY

Proceeding sequentially, we derive standards for medical professionalism from care quality criteria, neo-Hippocratic ethics, public health concepts, and policy outcomes. Thereby, we formulate benchmarks for health care management and apply them to policy evaluation. During this process we justify the social, professional - and by implication, non-commercial, non-industrial - mission of healthcare financing and policies. The complexity of ethical, person-centred, biopsychosocial practice requires a human interface between suffering, health risks and their therapeutic solution - and thus legitimises the medical profession's existence. Consequently, the universal human right to healthcare is a right to access professionally delivered care. Its enforcement requires significant updating of the existing medical culture, and not just in respect of the man/machine interface. This will allow physicians to focus on what artificial intelligence cannot do, or not do well. These duties should become the touchstone of their practice, knowledge and ethics. Artificial intelligence must support medical professionalism, not determine it. Because physicians need sufficient autonomy to exercise professional judgement, medical ethics will conflict with attempts to introduce clinical standardisation as a managerial paradigm, which is what happens when industrial-style management is applied to healthcare.

CONCLUSION

Public healthcare financing and policy ought to support medical professionalism, alongside integrated clinical and public health practice, and its management. Publicly-financed health management should actively promote ethics in publicly- oriented services. Commercialised healthcare is antithetical to ethical medical, and to clinical / public health practice integration. To lobby governments effectively, physicians need to appreciate the political economy of care.

Are formalised implementation activities associated with aspects of quality of care in general practice? A cross-sectional study

Background

There is a substantial variation in how different general practices manage knowledge implementation, including the degree to which activities are collectively and formally organised. Yet, it is unclear how these differences in implementation activities affect quality of care.

Aim

To investigate if there are associations between specific formalised knowledge implementation activities and quality of care in general practices, exemplified by the use of spirometry testing.

Design & setting

A nationwide cross-sectional study combining survey and register data in Denmark.

Method

An electronic questionnaire was distributed to GPs, and data on spirometry testing among first-time users of medication against obstructive lung diseases were obtained from national registers. Associations were investigated using multilevel mixed-effect logit models.

Results

GPs from 1114 practices (58%) responded, and 33 788 patients were linked to a responding practice. In partnership practices, the frequency of interdisciplinary and GP meetings affected the quality of care. Interdisciplinary and GP meetings held on a weekly basis were significantly associated with a higher level of quality of care and this was measured by the odds ratio (OR) of patients having spirometry. The development of practice protocols and standard recordings in the electronic medical record (EMR) for a range of disease areas compared with few or no areas at all also impacted the quality of care level provided. The effect of formalised implementation activities was not as evident in single-handed practices as in partnerships.

Conclusion

This study provides valuable knowledge for GPs who aim to organise their practice in a way that supports implementation and quality improvement most effectively. Also, results may be useful for managers of implementation strategies and quality improvement initiatives when planning future activities.