Exploring why quality circles work in primary health care: a realist review protocol

Using Implementation Mapping to develop an intervention program to support veterinarians' adherence to the guideline on Streptococcus suis clinical practice in weaned pigs

Streptococcus suis (S. suis) infections in weaned pigs are common and responsible for a high consumption of antimicrobials, and their presence is assumed to be multi-factorial. A specific evidence-based veterinary guideline to support the control of S. suis in weaned pigs was developed for veterinary practitioners in the Netherlands in 2014. Adherence to the S. suis clinical practice guideline helps veterinary practitioners to prevent and control the disease in a systematical approach and thereby improve antimicrobial stewardship and contribute to the prevention of antimicrobial resistance in animals and humans. The impact of such a clinical practice guideline on (animal) disease management depends not only on its content, but also largely on the extent to which practitioners adhere to the clinical guideline in practice. When the S. suis guideline was published, no specific activities were undertaken to support veterinarians' uptake and implementation, thereby contributing to suboptimal adherence in clinical practice. As the S. suis guideline was comprehensively written by veterinary experts following an evidence-based approach, our aim was not to judge the (scientific) quality of the guideline but to study the possibility to improve the currently low adherence of this guideline in veterinary practice. This paper describes the systematic development, using Implementation Mapping, of a theory-based intervention program to support swine veterinarians' adherence to the S. suis guideline. The knowledge, skills, beliefs about capabilities, and beliefs about consequences domains are addressed in the program, which includes seven evidence-based methods (modelling, tailoring, feedback, discussion, persuasive communication, active learning, and self-monitoring) for use in program activities such as a peer-learning meeting and an e-learning module. The intervention program has been developed for practicing swine veterinarians, lasts eight months, and is evaluated through a stepped-wedge design. The Implementation Mapping approach ensured that all relevant adopters and implementers were involved, and that outcomes, determinants (influencing factors), and objectives were systematically discussed.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits

BACKGROUND

Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs).

OBJECTIVES

To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits.

METHODS

A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration).

RESULTS

One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics.

CONCLUSIONS

Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

Finding common (research) ground between general practitioners and neuroscientists: the vital role of knowledge circulation in closing the evidence-to-practice gap

Background

It may take 15 years or longer before research evidence is integrated into clinical practice. This evidence-to-practice gap has deleterious effects on patients as well as research and clinical processes. Bringing clinical knowledge into the research process, however, has the potential to close the evidence-to-practice gap. The NEUROTRANS-Project attempts to bring research and practice together by focusing on two groups that usually operate separately in their communities: general practitioners and neuroscientists. Although both groups focus on dementia as an area of work, they do so in different contexts and without opportunities to share their expertise. Finding new treatment pathways for patients with dementia will require an equal knowledge exchange among researchers and clinicians along with the integration of that knowledge into research processes, so that both groups will benefit from the expertise of the other.

Methods

The NEUROTRANS-Project uses a qualitative, multi-stage research design to explore how neuroscientists and general practitioners (GPs) approach dementia. Using a grounded theory methodology, it analyzes semi-structured interviews, case vignettes, focus groups with GPs in Saxony-Anhalt, Germany, and informal conversations with, and observations of, neuroscientists from the German Center for Neurodegenerative Diseases in Magdeburg.

Results

The NEUROTRANS-Project identified a clear division of labor between two highly specialized professional groups. Neuroscientists focus abstractly on nosology whereas general practitioners tend to patient care following a hermeneutic approach integrating the patients’ perspective of illness. These different approaches to dementia create a barrier to constructive dialogue and the capacity of these groups to do research together with a common aim. Additionally, the broader system of research funding and health care within which the two groups operate reinforces their divide thereby limiting joint research capacity.

Conclusions

Overcoming barriers to research collaboration between general practitioners and neuroscientists requires a shift in perspective in which both groups actively engage with the other’s viewpoints to facilitate knowledge circulation (KC). Bringing ‘art into science and science into art’, i.e. amalgamating the hermeneutic approach with the perspective of nosology, is the first step in developing joint research agendas that have the potential to close the evidence-to-practice gap.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01560-3.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study

BACKGROUND

The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior.

OBJECTIVE

The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services.

DESIGN AND PARTICIPANTS

Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients.

INTERVENTIONS

Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018.

MAIN MEASURES

Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins.

KEY RESULTS

Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period.

CONCLUSION

Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

Exploring how and why Care Groups work to improve infant feeding practices in low- and middle-income countries: a realist review protocol

BACKGROUND

Within our inquiry into the implementation of breastfeeding policy in Malawi, Care Groups have been mentioned as a means to improve maternal and child health and nutrition outcomes. The 'Care Group model' is an approach primarily used in international development settings, whereby social and behaviour changes are promoted through supported peer-to-peer (mostly mother-to-mother) knowledge sharing. The aim of most Care Groups is to promote improved infant nutrition, improve hygiene and increase the number of children who are fully vaccinated and exclusively breastfed for the first 6 months. The behavioural changes promoted by Care Groups (such as safe infant feeding, frequent hand washing, consistent mosquito net usage, providing suitable complementary foods from 6 months old) have the potential of averting preventable deaths particularly among children under five. While a variety of approaches are used to promote improved health and nutrition for children under five, the Care Groups model was best known and frequently referenced during our discussions with key stakeholders regarding the delivery at community level of Malawi's National Multi-Sector Nutrition Policy 2018-2022. A better understanding of how Care Groups achieve their social and behaviour change results and how community-based efforts are sustained can potentially help to ensure more effective planning and budgeting for Care Group interventions and enable greater sustainability and increased coverage of infant feeding support countrywide. This realist review is designed to improve our understanding of how, why, to what extent and under what circumstances Care Groups improve infant feeding practices in low- and middle-income countries (LMICs).

METHODS AND ANALYSIS

A realist review is a theory-driven approach to evidence synthesis. To undertake this realist review, we will gather evidence by conducting peer-reviewed and grey literature database searches in order to find peer reviewed articles, programme guidelines and evaluation reports, among other texts, associated with the implementation of Care Groups in low- and middle-income countries. Our review process has five key steps: (1) locating existing theories; (2) searching for evidence in literature; (3) selecting articles and other suitable evidence; (4) extracting data, identifying configurations of context-mechanism-outcomes; and (5) synthesising the evidence, drawing conclusions.

DISCUSSION

The results of this realist review will be written up according to RAMESES guidelines and disseminated through a stakeholder workshop in Malawi, through conference presentations and peer-reviewed publications. It is intended to improve the understanding of the potential and limits of working through Care Groups globally and among relevant Malawi Ministry of Health staff and the donor and NGO community, both internationally and within Malawi. This systematic review protocol has been submitted for registration on the PROSPERO database (receipt number: 170261).

Implementation and Promotion of Quality Control Circle: A Starter for Quality Improvement in Chinese Hospitals

Purpose

To analyse the quality control circle (QCC) implementation status, tool modification and promotion in hospitals in mainland China.

Methods

Data were collected from the 2013–2018 National Quality Control Circle Competition of Chinese Hospitals. A total of 1913 participating QCCs implemented by 34,023 hospital staff from 915 hospitals across 31 provinces and municipalities were included in this study to analyse the characteristics of QCC implementation status in mainland China, using descriptive analyses.

Results

The majority of participating QCCs came from central and eastern hospitals. Most of the QCCs were carried out in tertiary hospitals and focused on themes of safety and patient care. The QCC has been modified in terms of its classification, implementation process, participation mechanism, and ways of dissemination. A series of promotion strategies have been made to promote the implementation of QCCs nationwide, including establishing a professional promotion organization, developing standardized training programmes, and organizing QCC academic events.

Conclusion

After years of promotion, QCCs are widely used in hospitals and have been modified to fit the practice of healthcare institutions. The QCC promotion strategies in China can offer valuable insights for other countries that are also making efforts to continuously improve care quality in healthcare institutions.

Where do Peer Review Groups fit in the international Continuing Professional Development literature?

OBJECTIVES

To describe what is reported in the Continuing Professional Development (CPD) literature on small group learning formats in medicine, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPD Peer Review Groups (PRGs).

METHOD

A literature review of international peer-reviewed publications in relation to the use of small group learning formats for CPD in medicine.

RESULTS

Small groups are commonly used as a learning format in medical CPD, primarily in general practice, but are little researched. Such groups take differing forms and they are valued by participants for a range of purposes, having effects on professionalism, clinical performance and doctors' wellbeing.

CONCLUSION

We believe that the contribution of these groups to medical CPD should be further explored. To this end, this review forms the first part of a research project focussing on the RANZCP PRG model used by Australian and New Zealand psychiatrists.

Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

Background

Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer.

Objective

Systematically assess CRC screening status of eligible 50–75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy).

Methods

Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50–75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients’ decisions.

Results

9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients’ chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests.

Conclusions

Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients’ chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients’ values and preferences were better respected.

Use of quality circles for primary care providers in 24 European countries: an online survey of European Society for Quality and Safety in family practice delegates

Objective: To identify and describe the core characteristics and the spread of quality circles in primary healthcare in European countries. Design: An online survey was conducted among European Society for Quality and Safety in Family Practice (EQuiP) delegates. To allow comparison with earlier results, a similar survey as in a study from 2000 was used. Setting: Primary Health Care in European countries. Subjects: General practitioners, delegated experts of the European Society for Quality and Safety in Family Practice (EQuiP). Main outcome measures: (1) Attendance in quality circles (2) their objectives (3) methods of quality improvement quality circles use (4) facilitator's role and training (5) role of institutions (6) supporting material and data sources quality circles use. Results: 76% of the delegates responded, representing 24 of 25 countries. In 13 countries, more than 10% of general practitioners participated in quality circles, compared with eight countries in 2000. The focus of quality circles moved from continuous medical education to quality improvement. Currently, quality circles groups use case-based discussions, educational materials and local opinion leaders in addition to audit and feedback. Some national institutions provide training for facilitators and data support for quality circle groups. Conclusion: The use of quality circles has increased in European countries with a shift in focus from continuous medical education to quality improvement. Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools. Qualitative inquiry is necessary to examine why QCs thrive or fail in different countries and systems. KEY POINTS Countries with already established quality circle movements increased their participation rate and extended their range of quality circle activities The focus of quality circles has moved from CME/CPD to quality improvement Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools Institutions should provide supporting material and training for facilitators.

Motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment: a realist review

OBJECTIVES

This review aimed to identify mechanisms underlying participation in falls prevention interventions, in older adults with cognitive impairment. In particular we studied the role of motivation.

DESIGN

A realist review of the literature.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, the Cochrane Library, PsycINFO and PEDRO.

ELIGIBILITY CRITERIA

Publications reporting exercise-based interventions for people with cognitive impairment, including dementia, living in the community.

DATA EXTRACTION AND SYNTHESIS

A 'rough programme theory' (a preliminary model of how an intervention works) was developed, tested against findings from the published literature and refined. Data were collected according to elements of the programme theory and not isolated to outcomes. Motivation emerged as a key element, and was prioritised for further study.

RESULTS

An individual will access mechanisms to support participation when they think that exercise will be beneficial to them. Supportive mechanisms include having a 'gate-keeper', such as a carer or therapist, who shares responsibility for the perception of exercise as beneficial. Lack of access to support decreases adherence and participation in exercise. Motivational mechanisms were particularly relevant for older adults with mild-to-moderate dementia, where the exercise intervention was multicomponent, in a preferred setting, at the correct intensity and level of progression, correctly supported and considered, and flexibly delivered.

CONCLUSION

Motivation is a key element enabling participation in exercise-based interventions for people with cognitive impairment. Many of the mechanisms identified in this review have parallels in motivational theory. Clinically relevant recommendations were derived and will be used to further develop and test a motivationally considered exercise-based falls intervention for people with mild dementia.

PROSPERO REGISTRATION NUMBER

CRD42015030169.

Nurturing the Virtues: Upholding Professionalism in the Midst of Busy Medical Practice

Tom L. Beauchamp and James F. Childress' (B&C) book Principles of Biomedical Ethics is well known for its four-principle approach to biomedical ethics. However, the authors also emphasize the importance of the virtues of health care personnel. After a short overview of virtue ethics, the five "focal virtues" described by B&C are discussed and applied to a chronic pain example. The question of how virtues are learned in the health care setting is addressed, and it is argued that virtues such as the ones defended by B&C are acquired when health care personnel are socialized in an environment dedicated to the continuous upholding of practices that aim at the telos of medicine. Viewed from this perspective, professional isolation can be considered to be dangerous; the upholding of medical professionalism throughout a whole career largely presupposing the existence of a community where virtues relevant to the practice of medicine are embodied and kept alive. The concept of professional socialization is important in that respect. Finally, some potential general implications of this view for continuing professional development are proposed.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

The use of quality circles as a support tool in the taking over of practices by young general practitioners

INTRODUCTION

Although informal meetings of healthcare professionals in smaller groups are common in the area of primary care in the Czech Republic, the method of quality circles is not in wide use. The aim of our project is to use this method to help new general practitioners (GPs) when they take over a medical practice and to suggest measures to improve the organization and overall attractiveness of new practices, as well as patient satisfaction.

MATERIALS AND METHODS

For the purposes of this observation, an already existing informal group formed by healthcare professionals and their trainees was used. The group met a total of four times in a 6-month period. In the first meeting, problematic areas were identified. In the second, specific issues of newly starting to practice were discussed, with time to consider suggestions for improvements. The third meeting consisted of an analysis of the suggested measures and their implementation, and in the fourth, these measures and their effects were evaluated.

RESULTS

On the basis of the discussion in the first and second meetings, suggestions were made, and then, during the third meeting, structured into three dimensions: (1) The organization of work, including clinical activities, (2) the attractiveness of the practice and the satisfaction levels of the patients, (3) the satisfaction levels of the employees. In each area, specific measures were proposed. The new doctors' feedback in the fourth phase of the project was positive. The main problems the new doctors faced were related to their lack of knowledge and experience with buying or starting their own practice, as well as being an effective team leader.

CONCLUSION

Despite the application of small groups being significantly larger, it was demonstrated that if GPs are given direction and clear goals in their meetings, these meetings can be very constructive. Small groups thus offer a good platform for young GPs in starting their own practice, giving them the capacity to do so.

Fostering needs assessment and access to medical rehabilitation for patients with chronic disease and endangered work ability: protocol of a multilevel evaluation on the effectiveness and efficacy of a CME intervention for general practitioners

BACKGROUND

Studies show that endangered work ability (EWA) can be maintained or restored through medical rehabilitation (MR). For patients, general practitioners (GP) represent an important point of access to MR in outpatient care. However, many different barriers and shortcomings hinder GPs in both timely detection of the need for MR and the recognition of its potentials for their EWA-patients. These are necessary if GPs are to adequately inform patients about MR options and successfully support applications for MR. This study describes the evaluation of a continuing medical education (CME) module designed to improve rehabilitation-related practical performance of GPs regarding a) subjective satisfaction of GPs with the CME module, b) stability of attitudes and knowledge over time regarding rehabilitation, and c) subjective and objective changes in MR-related competencies needed to support MR applications.

METHODS

This study is an open, non-randomised, pre-post-intervention study. The intervention involves a CME module for GPs (n = 1365) in the German state of Saxony-Anhalt on the topic of medical rehabilitation in connection with the federal German pension fund (Deutsche Rentenversicherung). The module will be initially held as regularly scheduled meetings in moderated GP quality circles (QC), and then offered as a written self-study unit. At the end it will be evaluated by the GPs. The study's primary focus is on the organizational practice as measured by the number of approved MR applications supported by medical reports submitted by the participating GPs in the 6 months before and 6 months after the CME module. Other study aims involve measuring self-perceived competencies of GPs, as well as their attitudes towards and knowledge of rehabilitation (both upon completing the CME and 6 months later). In addition, the level of satisfaction with the CME module will be analysed among participating GPs and QC moderators (as CME facilitators).

DISCUSSION

Implementing targeted CME on complex topics such as those involving barriers is possible, even promising, when using QCs and their moderators. Of particular importance is how aware moderating physicians are of the relevance of MR need detection and access.

ETHICS AND DISSEMINATION

The ethics committee of the Martin-Luther-Universität Halle-Wittenberg has registered this study under the number 2014-13. The study will be reported on in peer-reviewed journals and at national and international conferences. The results will be available to current and future initiatives aiming to improve detection of MR need and making MR accessible to EWEC patients needing such support to minimize the effects of chronic disease on their livess.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (ID number DRKS00006188) and WHO International Clinical Trials Registry Platform, Universal Trial Number (UTN) U1111-1158-8334.

Research protocol: a realist synthesis of contestability in community-based mental health markets

BACKGROUND

In most developed nations, there has been a shift from public services to a marketisation of public goods and services - representing a significant reform process aiming to transform the way in which community-based human services, such as health, are delivered and consumed. For services, this means developing the capacity to adapt and innovate in response to changing circumstances to achieve quality. The availability of rigorous research to demonstrate whether a market approach and contestability, in particular, is a coherent reform process is largely absent. Contestability operates on the premise that better procurement processes allow more providers to enter the market and compete for contracts. This is expected to create stimulus for greater efficiencies, innovation and improved service delivery to consumers. There is limited understanding, however, about how community-based providers morph and re-configure in response to the opportunities posed by contestability. This study focuses on the effect of a contestability policy on the community-managed mental health sector.

METHODS/DESIGN

A realist review will be undertaken to understand how and why the introduction of contestability into a previously incontestable market influences the ways in which community-based mental health providers respond to contestability. The review will investigate those circumstances that shape organisational response and generate outcomes through activating mechanisms. An early scoping has helped to formulate the initial program theory. A realist synthesis will be undertaken to identify relevant journal articles and grey literature. Data will be extracted in relation to the emerging contextual factors, mechanisms and outcomes and their configurations. The analysis will seek patterns and regularities in these configurations across the extracted data and will focus on addressing our theory-based questions.

DISCUSSION

Increasingly, community-based mental health markets are moving to contestability models. Rigorous research is needed to understand how such markets work and in what contexts. The knowledge gained from this study in community-based mental health will provide valuable lessons in how contestability works, in what circumstances and who benefits when. The results of the proposed research will be useful to policy-makers and may be applicable in other contexts beyond the community-based mental health sector.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015016808.