Høj Kirsten, Mygind Anna, Bro Flemming
Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.
Department of Public Health, Aarhus University, Aarhus, Denmark.
Implement Sci Commun. 2021 Jan 7;2(1):4. doi: 10.1186/s43058-020-00106-5.
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.
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.
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.
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.
潜在不适当处方（PIP）与不良健康后果及医疗成本增加相关。针对PIP的反馈干预已显示出有前景的结果。然而，从研究转化到日常实践仍然是一项挑战。以正常化过程理论（NPT）作为总体框架，我们旨在探讨在一项现实生活中的质量改进干预中，全科医疗实践所执行的实施过程，该干预使用了关于实践层面处方的反馈。
丹麦中部地区的所有376家全科医疗实践都接受了针对特定类型PIP的处方反馈干预。六个月后，他们收到一份评估问卷，45%的实践做出了回应。在报告因干预而做出改变的102家实践中，我们对10名全科医生进行了个人半结构化访谈。在基线处方状态、实施活动、实践类型和地理位置方面寻求最大程度的差异。使用NPT对访谈进行主题分析。
全科医疗实践中的实施过程反映了NPT的四个构成要素。实施的关键动机包括全科医生的专业价值观和兴趣，但务实的考虑也很重要（连贯性）。观察到在实施过程的参与和规划方面存在集体与个人的方法（认知参与）。同样，涉及整个实践团队的实践层面行动与单个全科医生执行的个人层面行动之间存在明显区别（集体行动）。确定了实施过程中的几个挑战，包括患者影响和多个层面相互竞争的优先事项（反思性监测）。此外，新实践在不同程度上发生了内部评估和正常化。
NPT为理解全科医疗实践中的实施过程提供了一个有用的框架。我们的结果强调，明确的专业目标和可行的干预内容是全科医生积极性的关键。这可以通过与全科医生的专业组织合作来确保，这可能会增强干预的合法性和接受度。确定了两种主要的实施策略：实践层面和全科医生层面的策略。干预开发者需要认识到这两种策略，以提供能够促进处方实践可持续改进的干预内容和实施支持。相互竞争的需求和患者影响仍然是重要挑战，未来研究需要解决这些问题，以进一步促进减少PIP。
