Implementation of remote asthma consulting in general practice in response to the COVID19 pandemic: evaluation using extended normalisation process theory

BackgroundThe COVID-19 pandemic has led to the rapid and reactive deployment of remote consulting in UK General Practice. The delivery of acute and chronic asthma care has been affected. Extended Normalisation Process Theory (eNPT) provides a framework for evaluating the implementation of new complex interventions in routine practice, including examination of how context-intervention interactions affect Implementation.AimTo explore the implementation of remote asthma consulting in UK General Practice in response to the COVID-19 pandemic.Design & settingMixed methods evaluation, informed by eNPT.SettingGeneral Practice in Northern Ireland.MethodData was collected from a range of healthcare professionals who provide asthma care using online questionnaires, interviews and multidisciplinary focus groups. Analysis was informed by eNPT.ResultsWe identified ten themes to describe and explain the contribution of General Practice staff to implementation of remote asthma consulting. Staff identified novel alternatives to in-person review. Having a practice champion to drive implementation forward, and engage other Practice staff, was important. Patient, staff and healthcare system contextual factors influencing implementation were identified including access to, understanding of and willingness to use the technology required for remote consulting.ConclusionThe experiences of frontline healthcare professionals in this study indicate that remote asthma consulting has potential benefits in terms of access and effectiveness when implementation integrates seamlessly with face-to-face care for those who want or need it. Work is required at Practice and healthcare system levels to realise this potential, and ensure implementation does not exacerbate existing healthcare inequalities.

The impact of COVID-19 on practice learning in nurse education

The COVID-19 pandemic has impacted healthcare education and delivery, including both theory and practice learning. Academic staff responded rapidly to move teaching online during the first lockdown, with many returning to practice to deliver care or upskill practice staff to work in critical care. Many pre-registration students responded by becoming paid NHS employees, contributing to care delivery while remaining on their programme of study. Practice learning partners, despite the challenges of the pandemic, continued to support students to achieve their registration status. This occurred within the context of the Emergency and Recovery Standards, published by the Nursing and Midwifery Council between March 2020 and September 2021. This paper sets out the response of students, practice learning partners and higher education institutions involved in pre-registration nursing and midwifery programmes.

Undertaking general practice quality improvement to improve cancer screening - a thematic analysis of provider experiences

Background Cancer is a major cause of illness and death, and its incidence and mortality can be reduced through effective screening. In order to improve below target screening rates in one region of Australia, the local Primary Health Network supported local general practices to implement a range of quality improvement initiatives. Methods We used a qualitative approach and interviewed 18 general practice staff and five Primary Health Network staff and contractors to understand their experiences with these quality improvement initiatives. Results In a thematic analysis, we identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. Program roles were clear and understood, and the program received strong oversight and support. Practice staff felt supported and motivated. Information Technology was a challenge for many practices often requiring tailored assistance. Education provided by practices facilitated patient empowerment but practice staff noted difficulties engaging patients in screening. Practices were enhanced though strong leadership and teamwork and practice learning activities. Conclusions The tailored evidence-based quality improvement initiatives were considered effective in supporting general practices to increase their cancer screening. Key facilitators reported by participants included use of Plan-Do-Study-Act cycles, enhanced data entry and audit capacity, effective recall and reminder systems and maintaining staff motivation.

Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review

ObjectiveTo identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing.SettingPrimary care.Data sourcesMedline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021.Study selectionIncluded studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations.Data extractionScreening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles.ResultsFifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added.ConclusionActivities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.

How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices

IntroductionThe COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic.Methods and analysisThis is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020–2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic.Ethics and disseminationEthics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.

Protocol for a process evaluation of an external pilot cluster randomised controlled trial of a theory-based intervention to improve appropriate polypharmacy in older people in primary care: the PolyPrime study

Background The PolyPrime intervention is a theory-based intervention aimed at improving appropriate polypharmacy in older people (aged ≥65 years) in primary care. The intervention consists of an online video which demonstrates how general practitioners (GPs) can prescribe appropriate polypharmacy during a consultation with an older patient and a patient recall process, whereby patients are invited to scheduled medication review consultations with GPs. The aim of the process evaluation is to further examine the implementation of the PolyPrime intervention in primary care. This will involve investigating whether the PolyPrime intervention can be delivered as intended across two healthcare systems, how acceptable the intervention is to GPs, practice staff and patients, and to identify the intervention’s likely mechanisms of action. Methods The PolyPrime study is an external pilot cluster randomised controlled trial (cRCT) which aims to recruit 12 GP practices across Northern Ireland [NI] (n=6) and the six counties in the Republic of Ireland (ROI) that border NI (n=6). Practices have been randomised to intervention or usual care. An embedded process evaluation will assess intervention fidelity (i.e. was the intervention delivered as intended), acceptability of the intervention to GPs, practice staff and patients and potential mechanisms of action (i.e. what components of the intervention were perceived to be effective). Quantitative data will be collected from data collection forms completed by GPs and practice staff and a feedback questionnaire completed by patients from intervention arm practices, which will be analysed using descriptive statistics. Qualitative data will be collected through semi-structured interviews with GPs and practice staff and audio-recordings of medication review appointments from the intervention arm practices which will be transcribed and analysed using the framework method. Quantitative and qualitative data will be triangulated to provide an overall assessment of intervention fidelity, intervention acceptability, and mechanisms of action. Discussion This process evaluation will add to feasibility data from the pilot cRCT by providing evidence on the fidelity of implementing the intervention package across two healthcare systems, the acceptability of the intervention and potential mechanisms of action. Trial registration ClinicalTrials.govISRCTN41009897. Registered on 19 November 2019. ClinicalTrials.govNCT04181879. Registered 02 December 2019.

A pandemic of abuse against general practice staff

With a survey revealing as many as three quarters of practice staff receive abuse from patients daily, more needs to be done to prevent and deal with this rising tide of insults, threats and violence, reports Kathy Oxtoby

‘Function First’: how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods

ObjectivesTo develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory.DesignRealist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation.ResultsA taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions.Abridged realist programme theoryRoutinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy.Co-designThe programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change.ConclusionsPrevious physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

Undertaking General Practice Quality Improvement to Improve Cancer Screening - A Thematic Analysis of Provider Experiences

Background: Cancer is a major cause of illness and death, and its incidence and mortality can be reduced through effective screening. In order to improve below target screening rates in one region of Australia, the local Primary Health Network supported local general practices to implement a range of quality improvement initiatives.Methods: We used a qualitative approach and interviewed 16 general practice staff and five Primary Health Network staff and contractors to understand their experiences with these quality improvement initiatives.Results: In a thematic analysis, we identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. Program roles were clear and understood, and the program received strong oversight and support. Practice staff felt supported and motivated. Information Technology was a challenge for many practices often requiring tailored assistance. Education provided by practices facilitated patient empowerment but practice staff noted difficulties engaging patients in screening. Practices were enhanced though strong leadership and teamwork and practice learning activities.Conclusions: The tailored evidence-based quality improvement initiatives were considered effective in supporting general practices to increase their cancer screening. Key facilitators reported by participants included use of Plan-Do-Study-Act cycles, enhanced data entry and audit capacity, effective recall and reminder systems and maintaining staff motivation.