Background
Methods
Study population
Qualitative sampling
Data collection
Data analysis
Results
Domain | Research focus | Data source | Main findings |
---|---|---|---|
Recruitment of practices | How were practices sampled and recruited? Reasons for non-participation? | Study team recruitment logs | Practices recruited from the HRB primary care research network by email with follow-up call. Recruitment modest, main reason for declining was practice being too busy. |
Delivery to practices | What intervention is delivered for each practice? Is it the one intended by the researchers? | Semi-structured interviews | Academic detailing delivered to intervention practices as planned. Letters sent to control practices as planned. |
Response of practices | How is the intervention adopted by clusters? | Website activity, semi-structured interviews | Medication reviews conducted as planned by eight (73 %) intervention practices, two (18 %) conducted reviews without patients present. Two (20 %) control practices made changes to patients. |
Recruitment and reach in individuals | Who actually receives the intervention in each setting? Are they representative? | Study team recruitment logs, patient questionnaire data | Patients recruited broadly similar to national population demographically. |
Delivery to individuals | Who received medication reviews? | Semi-structured interviews, website activity | Eighty-six patients had reviews, one practice conducted no reviews. |
How were reviews conducted? | Semi-structured interviews | Eight intervention practices conducted reviews with patients, two practices conducted reviews without patients present. | |
What were the outcomes of the reviews? | Website activity | Most common outcome – dose reduction. | |
Responses of individuals | How does the target population respond? | Semi-structured interviews | Patients happy to participate and valued the opportunity to review unnecessary medication. |
Recruitment of practices
Characteristic | Study participants | National population |
---|---|---|
GP practice | ||
Practice type | ||
GMS and private | 100 % | 96.0 %a
|
GMS list size | ||
500 or less | 14.3 % | 29.8 %b
|
501–1500 | 23.8 % | 59.6 %b
|
1501–2500 | 61.9 % | 10.6 %b
|
Practice staff | ||
Single-handed GP | 14.3 % | 35.0 %a
|
2+ GPs | 85.7 % | 65.0 %a
|
Practice manager | 71.4 % | 30.0 %a
|
Practice location | ||
Urban | 76.2 % | 43.0 %a
|
Mixed | 23.8 % | 36.0 %a
|
Teaching activity | 100 % | 42.0 %a
|
Patients | ||
Total population | ||
Male | 105 (53.6 %) | 157,016 (43.4 %)c
|
Age category | ||
70–75 | 94 (48.5 %) | 154,286 (42.6 %)c
|
76–80 | 58 (29.7 %) | 95,894 (26.5 %)c
|
81–85 | 35 (17.9 %) | 63,406 (17.5 %)c
|
86–90 | 6 (3.1 %) | 34,358 (9.5 %)c
|
91 and over | 2 (1.0 %) | 13,811 (3.8 %)c
|
Marital status | ||
Married | 107 (54.9 %) | 170,560 (47.1 %)c
|
Single | 24 (12.3 %) | 55,371 (15.3 %)c
|
Widowed | 58 (29.7 %) | 125,551 (34.7 %)c
|
Divorced | 3 (1.5 %) | 3,767 (1.0 %)c
|
Separated | 2 (1.0 %) | 6,506 (1.8 %)c
|
GMS card holder | 183 (93.4 %) | 360,000 (96.0 %)b
|
Delivery to practices
Response of practices: how the intervention was adopted
Intervention group practices
“I think it’s probably easier in this practice because it is single-handed. Ok, you know, it’s not like I’m changing something that one of my colleagues put them on and said to them, you must stay on this or whatever, they all deal with me, for better or worse – I don’t know!” (GP21, intervention practice).
“I didn’t have to, you know, the whole process is that our patients, if they trust us, and we explain everything to them, what we are doing, em, you don’t need to, we don’t need to do that [give PILs].” (GP16, intervention practice).
“Oh no, no, I don’t welcome those sorts of things; they just pile up here in the house.” (P13.47, intervention patient).
“Oh yeah, it was very good, yeah, because actually, because they were coming in you were able to look at everything properly and they were coming in a structured review … just to give you a time to review the whole situation you know, in regards to all of their prescribing. It was very useful, yeah.” (GP18, intervention practice).
“It was very straightforward, it worked well I thought, em it was clear and you know, from our point of view, actually when you actually got down to it, the patient, the actual process of going through the patient was quite quick.” (GP24, intervention practice).
“I actually think that this study has made me review my patients more closely, so I think it’s good for me personally, which means it’s good for my patients in the end.” (GP23, intervention practice).
“That was difficult, because, the person who manages such things is [practice nurse], who was on sick leave for most of the study. So there was nobody driving the process because [practice nurse] was away, we had only very little nursing cover in her absence, then we were doing tasks that would have been previously done by the nurse, so it was a very busy time.” (GP7, intervention practice).×
Control group practices
“What I did was, I went in to all the files and I did a mail merge and wrote to them and changed their meds. So basically, there was a PPI - reduce the dose by half, so I just did that immediately and told them that I did that and why.” (GP3, control practice).
Recruitment and reach of individuals (patients)
“I resented the reminders … I had underestimated the amount of involvement it would require from the practice. That’s what I would say.” (GP7, intervention practice).
Delivery to individuals (patients)
Review outcomes
“Sometimes, for example, in relation to benzodiazepine, em, you know, somebody might be on benzodiazepines and has been for 40 years, which one of the patients actually was, I don’t think it’s appropriate to stop that. If they’re stable and they can get on with their lives then I think it would cause more hassle for them.” (GP1, intervention practice).
Response of individuals (patients) to the medicines review process
Main theme | Sub-theme | Example quote |
---|---|---|
Delivery to practices | Academic detailing quality | “Yes, that was very informative, very straightforward, very user friendly.” (GP16, intervention practice) |
Response of intervention group | Adoption as planned | “O yeah, it was very good, yeah, because actually, because they were coming in you were able to look at everything properly and they were coming in a structured review .... .just to give you a time to review the whole situation you know, in regards to all of their prescribing. It was very useful, yeah.” (GP18, intervention practice). |
Adaptation I. Reviews without patients | “So I didn’t do it with the patients but what I did was, I think you saw from the patient records, I highlighted the notes on it, and I’d have put tags on charts when I found, yeah that needs to be done, to be addressed with their next prescription. (GP21, intervention practice). | |
II. Patient information leaflet non-use | “I didn’t have to, you know, the whole process is that our patients, if they trust us, and we explain everything to them, what we are doing, em, you don’t need to, we don’t need to do that [give PILs].” (GP16, intervention practice). | |
Facilitators of implementation I. Simplicity | “It was very straightforward, it worked well I thought, em it was clear and you know, from our point of view, actually when you actually got down to it, the patient, the actual process of going through the patient was quite quick.” (GP24, intervention practice). | |
II. Patient receptivity | “Absolutely no problem at all. And in fact, if anything they were quite glad, you know, that somebody is looking at their medications and making sure that it is OK, and all the rest.” (GP1, intervention practice). | |
Barriers of implementation I. Staff | “That was difficult, because, the person who manages such things is [practice nurse], who was on sick leave for most of the study. So there was nobody driving the process because [practice nurse] was away, we had only very little nursing cover in her absence, then we were doing tasks that would have been previously done by the nurse, so it was a very busy time.” (GP7, intervention practice). | |
Response of control group | Adaptation | “What I did was, I went in to all the files and I did a mail merge and wrote to them and changed their meds. So basically, there was a PPI - reduce the dose by half, so I just did that immediately and told them that I did that and why.” (GP3, control practice). |
Recruitment and reach in individuals | Recruitment burden | “I resented the reminders … I had underestimated the amount of involvement it would require from the practice. That’s what I would say” (GP7, intervention practice) |
Responses of individuals | Benefits of reviews I. Quality of care | “I think it is important really, because it makes people feel, well, you know that there is somebody that cares. You know, as you are getting older, that there is somebody that cares about the elderly, that they, you know, are being properly looked after and people are thinking about them.” P23.38 |
II. Societal good | “I’m sure, I’m absolutely sure, there through not the patient’s fault, eh, there must be an amazing amount of pharmaceutical waste consumed by patients who don’t really eh, need it. And as you say, the purpose of your exercise is to find out if some of these can be dropped. In fact, I’m sure they could be and, the monies saved by the State could eh, be put into looking after the less fortunate people.” P1.61 | |
III. Necessary medication | “You’re inclined to go on things and be left on them and then you wonder should you be on them all that time, is there any side effects with them, all that kinda thing.” P7.4 | |
Barriers to reviews I. GP workload | “Well, I mean, if my, if my GP has time to do that sort of thing then fine, you know.” P18.48 | |
Future implementation | Facilitators I. Positive aspiration | “When you are a GP you get practices and you get bad habits, and you get good habits, and sometimes you are too busy to change your habits until it is pointed out so, anything like this is a good thing.” (GP19, control practice). |
II. Cardinal PIPs | “I think that if you keep it simple, and maybe in a structured way if you could layer it, so that you know, for 2012 we are focusing on these five issues and in 2013 we’re focusing on these, you know. There would be a little bit of slippage with last year’s issues, but over time you would introduce better prescribing.” (GP13, intervention practice). | |
Barriers I. Workload | “General practice at the moment now, as far as I can see, is getting hit by about 30 % more extra work, due to the economic downturn, so most medical card list have gone up by about 30 %, and that is increasing a huge volume of work, because those patients before, happened to be in the non-medical card area and they weren’t consulting as much. So they are now consulting, eh, much more frequently so it’s very little time left … if you had to do that every 6 months, to review all those patients. Where would you get the time?” (GP5, control practice). | |
II. Reimbursement | “I often wonder if the government was to pay a fee for us to review ten patients every 3 months formally, but they’re going to say, we’re already paying you to do these prescriptions, to write these prescriptions you know, like come on guys, and they are right.” (GP13, intervention practice). |
Future implementation: GP perspective
“When you are a GP you get practices and you get bad habits, and you get good habits, and sometimes you are too busy to change your habits until it is pointed out so, anything like this is a good thing.” (GP19, control practice).
“General practice at the moment now, as far as I can see, is getting hit by about 30 % more extra work, due to the economic downturn, so most medical card list have gone up by about 30 %, and that is increasing a huge volume of work, because those patients before, happened to be in the non-medical card area and they weren’t consulting as much. So they are now consulting, eh, much more frequently so it’s very little time left … if you had to do that every 6 months, to review all those patients. Where would you get the time?” (GP5 control practice).
“I think that if you keep it simple, and maybe in a structured way if you could layer it, so that you know, for 2012 we are focusing on these five issues and in 2013 we’re focusing on these, you know. There would be a little bit of slippage with last year’s issues, but over time you would introduce better prescribing.” (GP13, intervention practice).
“I often wonder if the government was to pay a fee for us to review ten patients every 3 months formally, but they’re going to say, we’re already paying you to do these prescriptions, to write these prescriptions you know, like come on guys, and they are right.” (GP13, intervention practice).“Unless it’s free they won’t come in and even if it is free, I don’t know, it’s difficult to get them in you know. Em, if they are paying, definitely they won’t want to come in to do something that they think is for your benefit and not for theirs you know.” (GP18, intervention practice).
Discussion
Intervention implementation
Participant experience
Future implementation
Strengths and limitations of this study
Lessons learnt and future research
• Complex interventions in primary care are often not implemented and utilised as intended. • Intervention delivery may vary by practice characteristics such as number of GPs and practice resources. • Recruitment continues to be one of the most challenging aspects of conducting trials in primary care. In this setting, computerisation of patient identification would decrease the requirements placed on GPs at the start of the study and speed up the recruitment process. • Involving patients in medication reviews has the potential to decrease inappropriate prescribing. • Targeting a smaller number of specific medication groups or “cardinal PIPs” emerged as an important facilitator in overcoming workload barriers. • Process evaluations are more informative when they incorporate both qualitative and quantitative research methods. |