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

"We don't need no education" - a qualitative study of barriers to continuous medical education among Danish general practitioners

BACKGROUND

Continuous medical education is essential for the individual patient care, the society, and the wellbeing of the general practitioner. There has been research into the reasons for participation in continuous medical education, but little is known about the barriers to participation. To tailor continuous medical education targeting general practitioners who are currently deselecting education, systematic knowledge of the barriers is needed. Continuous medical education can in addition to professional growth stimulate job satisfaction, diminish burnout, and reinforce feelings of competence. Continuous medical education may have positive implications for patients and for healthcare expenditures. Despite renumeration and a comprehensive continuous education model some Danish general practitioners do not participate in continuous medical education.

METHODS

From a total of 3440 Danish general practitioners 243 did not apply for reimbursement for accredited continuous medical education in a two-year period. Ten general practitioners were selected for an interview regarding maximum variation in practice form, number of listed patients, seniority as a general practitioner, geography, gender, and age. All ten selected general practitioners accepted to be interviewed. The interviews were analysed using Systematic Text Condensation.

RESULTS

Each of the ten interviewed general practitioners mentioned several barriers for participating in continuous education. The barriers fell into three main categories: barriers related to the individual general practitioner barriers related to the clinic barriers related to the accredited continuous medical education offered CONCLUSIONS: Approximately 7% of the Danish general practitioners did not participate in accredited remunerated continuous medical education. A knowledge of the barriers for participating in accredited continuous medical education can be used to better target continuous medical education to the general practitioners.

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.

Associations between degrees of task delegation and adherence to COPD guidelines on spirometry testing in general practice - a national cross-sectional study

Background

The healthcare systems in the western world have in recent years faced major challenges caused by demographic changes and altered patterns of diseases as well as political decisions influencing the organisation of healthcare provisions. General practitioners are encouraged to delegate more clinical tasks to their staff in order to respond to the changing circumstances. Nevertheless, the degree of task delegation varies substantially between general practices, and how these different degrees affect the quality of care for the patients is currently not known. Using chronic obstructive pulmonary disease (COPD) as our case scenario, the aim of the study was to investigate associations between degrees of task delegation in general practice and spirometry testing as a measure of quality of care.

Methods

We carried out a cross-sectional study comprising all general practices in Denmark and patients suffering from chronic obstructive pulmonary disease. General practitioners (GPs) were invited to participate in a survey investigating degrees of task delegation in their clinics. Data were linked to national registers on spirometry testing among patients with COPD. We investigated associations using multilevel mixed-effects logit models and adjusted for practice and patient characteristics.

Results

GPs from 895 practices with staff managing COPD-related tasks responded, and 61,223 COPD patients were linked to these practices. Hereof, 24,685 (40.3%) had a spirometry performed within a year. Patients had a statistically significant higher odds ratio (OR) of having an annual spirometry performed in practices with medium or maximal degrees of task delegation compared to practices with a minimal degree (OR = 1.27 and OR = 1.33, respectively).

Conclusion

Delegating more complex tasks to practice staff implies that COPD-patients are more likely to be treated according to evidence-based recommendations on spirometry testing.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4270-3) contains supplementary material, which is available to authorized users.