Grant Aileen, Dreischulte Tobias, Guthrie Bruce
School of Health Sciences and Sport, University of Stirling, Stirling, UK.
Medicines Governance Unit, NHS Tayside, Dundee, UK.
BMJ Open. 2017 Mar 10;7(3):e015281. doi: 10.1136/bmjopen-2016-015281.
To explore how different practices responded to the Data-driven Quality Improvement in Primary Care (DQIP) intervention in terms of their adoption of the work, reorganisation to deliver the intended change in care to patients, and whether implementation was sustained over time.
Mixed-methods parallel process evaluation of a cluster trial, reporting the comparative case study of purposively selected practices.
Ten (30%) primary care practices participating in the trial from Scotland, UK.
Four practices were sampled because they had large rapid reductions in targeted prescribing. They all had internal agreement that the topic mattered, made early plans to implement including assigning responsibility for work and regularly evaluated progress. However, how they internally organised the work varied. Six practices were sampled because they had initial implementation failure. Implementation failure occurred at different stages depending on practice context, including internal disagreement about whether the work was worthwhile, and intention but lack of capacity to implement or sustain implementation due to unfilled posts or sickness. Practice context was not fixed, and most practices with initial failed implementation adapted to deliver at least some elements. All interviewed participants valued the intervention because it was an innovative way to address on an important aspect of safety (although one of the non-interviewed general practitioners in one practice disagreed with this). Participants felt that reviewing existing prescribing did influence their future initiation of targeted drugs, but raised concerns about sustainability.
Variation in implementation and effectiveness was associated with differences in how practices valued, engaged with and sustained the work required. Initial implementation failure varied with practice context, but was not static, with most practices at least partially implementing by the end of the trial. Practices organised their delivery of changed care to patients in ways which suited their context, emphasising the importance of flexibility in any future widespread implementation.
NCT01425502.
探讨不同医疗机构在采用《初级医疗数据驱动的质量改进》（DQIP）干预措施方面的情况，包括其对该工作的采用情况、为向患者提供预期的护理改变而进行的重组情况，以及实施是否能长期持续。
对一项整群试验进行混合方法并行过程评估，报告有目的地选择的医疗机构的比较案例研究。
来自英国苏格兰的10家（占30%）参与试验的初级医疗医疗机构。
选取了4家医疗机构作为样本，因为它们在目标处方方面有大幅快速减少。它们内部都一致认为该主题很重要，早早制定了实施计划，包括分配工作责任并定期评估进展。然而，它们内部组织工作的方式各不相同。选取了6家医疗机构作为样本，因为它们最初实施失败。实施失败发生在不同阶段，具体取决于医疗机构的情况，包括内部对于该工作是否值得存在分歧，以及虽有意愿但由于职位空缺或疾病而缺乏实施或持续实施的能力。医疗机构的情况并非一成不变，大多数最初实施失败的医疗机构都进行了调整，至少实施了一些要素。所有接受访谈的参与者都重视该干预措施，因为它是解决安全重要方面的一种创新方式（尽管一家医疗机构中一名未接受访谈的全科医生不同意这一点）。参与者认为审查现有处方确实影响了他们未来使用目标药物的起始情况，但对可持续性表示担忧。
实施和效果的差异与医疗机构对所需工作的重视程度、参与程度和持续程度的差异有关。最初的实施失败因医疗机构情况而异，但并非固定不变，大多数医疗机构在试验结束时至少部分实施了该措施。医疗机构以适合自身情况的方式组织向患者提供改变后的护理，强调了在未来广泛实施中灵活性的重要性。
NCT01425502。
