Organizing cardiovascular preventive care in general practice: determinants of a successful intervention

Exploring the content and delivery of feedback facilitation co-interventions: a systematic review

BACKGROUND

Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials.

METHODS

We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively.

RESULTS

We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time.

CONCLUSIONS

Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible.

REVIEW REGISTRATION

The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .

Sustainable practice change: professionals' experiences with a multisectoral child health promotion programme in Sweden

Background

New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.

Methods

All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n = 23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for programme sustainability.

Results

The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for programme sustainability.

Conclusions

These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a programme requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.

Did a health dialogue matter? Self-reported cardiovascular disease and diabetes 11 years after health screening

OBJECTIVE

To study the potential impact of health screening, with or without a motivational health dialogue, on the risk and morbidity of cardiovascular diseases (CVD) and diabetes (DM).

DESIGN

Two cross-sectional studies with an interval of 11 years.

SETTING

The community of Härnösand, Sweden.

SUBJECTS

In the first study, 402 men born in 1934, 1944, or 1954 underwent health screening for CVD prevention in 1989. In the second study, 415 men (of the same ages) completed a questionnaire in 2000 (11 years later).

MAIN OUTCOME MEASURES

Odds ratio (OR) for self-reported CVD and DM.

RESULTS

The odds ratio of self-reported CVD and DM was more than doubled among participants in the health screening without a health dialogue (OR 2.5; 95% CI 0.8-7.4) and threefold for those not participating (OR 3.0; 95% CI 1.0-8.8) compared with those who reported participation in health screening that included a structured health dialogue.

CONCLUSIONS

Health screening for the prevention of CVD and DM benefits from inclusion of a structured, motivational health dialogue.

Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians

BACKGROUND

There is nonoptimal adherence of general practitioners (GPs) and patients to cardiovascular risk reducing interventions. GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk. In addition, communicating cardiovascular risk to patients has proved to be difficult.

AIMS

Improving primary prevention of cardiovascular disease (CVD) in primary care by enhancing patient involvement in the use of a decision support tool.

DESIGN

Cluster randomized trial.

METHODS

Thirty-four GPs included patients (40-75 years old) without CVD. In an interactive, small group training session lasting 4 h, the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool. The control group received educational materials about the guidelines on paper. GPs' clinical performance and patients' risk perception and self-reported lifestyles were measured at baseline and after 6 months.

RESULTS

Thirty-four GPs recorded 490 consultations, 276 in the intervention and 214 in the control group. After 6 months, no significant effect of the intervention on the GPs' performance or the patients' risk perception was found. There was only an effect on self-reported lifestyle, in that more men in the intervention group than in the control group increased their physical activity (odds ratio 3.8, 95% confidence interval 1.7-8.7).

CONCLUSION

The 4-h interactive, small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs' performance or correct patients' risk perception. The positive effect on physical activity justifies further research on patient involvement.

Assessment of intervention intensity: experiences from a small-scale Swedish cardiovascular disease prevention programme

AIMS

To study the context of an intervention programme, including possible competing demands between an intervention and other health service assignments, and to develop a measure of intervention intensity.

METHODS

Data used include questionnaires and interviews with intervention staff, protocols, and reports from the intervention programme, and cross-sectional health surveys. A new Intervention Intensity Score (IIS) is used as an indicator of the intensity of the intervention.

RESULTS

Initially the intensity of support and activity of the programme was high and some cardiovascular risk factors such as cholesterol and daily smoking declined. There were favourable allocations of resources in the setting and enthusiasm. Later, disturbing changes in the organisation, competing demands within Primary Health Care (PHC), and an incipient decline of the intervention intensity occurred. These changes accelerated and finally the intervention intensity faded out, parallel to unfavourable risk factor changes. The Intervention Intensity Score (IIS) is useful as an indicator in the interpretation of programme effectiveness.

CONCLUSIONS

The amount and quality of support, the intervention process itself, and the intervention intensity were determining factors of the achievements of this intervention programme. The IIS measure used in this study provides a feasible way to interpret and understand achievements and shortcomings of the intervention programme.

Revisiting "Success": Posttrial analysis of a gender-specific HIV/STD prevention intervention

Alongside the recognized need to foster the development of innovative gender-specific HIV interventions, researchers face the urgent need to further understand how current interventions do or do not work. Few studies build posttrial qualitative analysis into standardized interview assessments in randomized controlled trials in order to bolster an assessment of how interventions work. The current investigation is a posttrial qualitative analysis carried out on a randomly selected subsample (N = 180), representing 50% of women who participated in a 3-arm randomized controlled trial known as Project FIO (The Future Is Ours). FIO was a gender-specific HIV prevention intervention carried out with heterosexually active women in a high seroprevalence area of New York City. Posttrial qualitative results extend an understanding of the success of the trial (e.g., reductions in unsafe sex). Qualitative results reflect how the Modified AIDS Risk Reduction Model operated in the expected direction across experimental groups. Results also highlight women's empowerment narratives, reflecting the salience of bodily and sexual rights aspects of the intervention.

Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice

OBJECTIVE

To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care.

DESIGN

Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years.

SETTING

124 general practices in The Netherlands.

PARTICIPANTS

185 GPs.

MAIN OUTCOME MEASURES

Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs.

RESULTS

The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention.

CONCLUSIONS

Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development.