Recruiting general practitioners and patients with dementia into a cluster randomised controlled trial: strategies, barriers and facilitators

Experiences with implementing advance care planning (ACP-GP) in Belgian general practice in the context of a cluster RCT: a process evaluation using the RE-AIM framework

BACKGROUND

General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results.

METHODS

We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions.

RESULTS

Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future.

CONCLUSIONS

Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice.

TRIAL REGISTRATION

ISRCTN12995230; prospectively registered on 19/06/2020.

Primary care involvement in clinical research - prerequisites, motivators, and barriers: results from a study series

BACKGROUND

Long-term reinforcement in the role of primary care and improvement the healthcare system as a whole requires the involvement of GPs in clinical research processes. However, many clinical studies fail due to failure to achieve sample population targets amongst GPs and their patients. This issue has been identified and discussed, but effective strategies to overcome it are still lacking. One of the reasons is that the positions, requirements, and experiences of GPs on participating in clinical research have hardly been examined up to now.

METHODS

The years 2021 and 2022 saw three quantitative and qualitative surveys amongst GPs in Germany with the aim of shedding light on the attitudes, experiences, and potential issues regarding the involvement of primary care in clinical research projects and participation in cluster-randomised controlled trials (cRCTs) in a general sense. This overview summarises and abstracts conclusions gained from the exploratory series of studies and compares the results with the current research situation. From here, this contribution will then develop an approach towards optimising the integration of GPs into clinical research.

RESULTS

Most of the GPs asked associated clinical research with opportunities and potential such as closing gaps in healthcare, using evidence-based instruments, optimising diagnostic and therapeutic management, and reinforcement of multiprofessional healthcare. Even so, many GPs unsure as to how far primary care in particular would stand to benefit from studies of this type in the long term. Respondents were also divided on willingness to participate in clinical research. GPs having already participated in Innovation Fund projects generally saw a benefit regarding intervention and cost-benefit relationship. However, some also reported major hurdles and stress factors such as excessive documentation and enrolment requirements, greater interference in practice routines, and sometimes poor integration into project processes such as in communication and opportunities to play an active role in the project.

CONCLUSIONS

Results from the studies presented provide indications as to how GPs perceive clinical research projects and cRCTs as a whole and from their existing project experience, and on the requirements that studies would have to meet for GPs to be willing to participate. In particular, making sure that clinical studies fully conform with GPs would play a major role; this especially applies to freedom to make medical decisions, limitation of documentation obligations, interference in regular practice routine, greater involvement in research planning, and long-term reinforcement in the role of primary care. Clinical research projects and cRCTs should be planned, designed, and communicated for clear and visible relevance to everyday primary care.

Starting a career in research nursing during a global pandemic

In the spring of 2020, two nurses (KR and AJ) commenced their research nurse careers amid the SARS-Cov-2 (COVID-19) global pandemic. This reflective article discusses their experiences of beginning a clinical research nursing career, presented as a case study of their learning journey, rather than detailing the randomised controlled trial they delivered via GP practices. The main study compared standard care to nurse-led management of irritable bowel syndrome, the details of which will be published separately. The article identifies three overarching concepts: 'Green as grass, keen as mustard', 'Spires and steeples', and 'Down the rabbit hole'. The article offers insight from the two nurses for other professionals contemplating a career in research.

Experiences with Innovation Fund healthcare models in primary care: a qualitative study amongst German general practitioners

The Innovation Fund was set up in 2015 with the aim of improving medical care in the German statutory health insurance system. Primary care needs to be involved in testing interventions and new forms of care for effectiveness and inclusion in standard care. There has so far been hardly any research on how far Innovation Fund models accommodate the primary care setting, or on the experience general practitioners have had with these models. Between September 2021 and January 2022, 36 semi-standardized individual interviews were performed with general practitioners who had already participated in Innovation Fund projects. Eleven regional physician networks in Rhineland-Palatinate, Hesse, North Rhine-Westphalia, and Schleswig-Holstein were involved in the recruitment process. Most of the interviewees associated the Innovation Fund with potential and opportunity including intensification of application-oriented healthcare research, independent financing, and general healthcare involvement. Even so, many general practitioners were unsure as to how far primary care in particular would stand to benefit from the Innovation Fund in the long term. A mostly positive balance was drawn from participation in care models-benefit of intervention as well as cost-benefit ratio. However, some also reported hurdles and stress factors such as documentation requirements and disruption in everyday office routine. Innovation Fund projects will need to be suitable for general practitioners especially regarding medical decision-making leeway, limits to documentation requirements, preserving established office routine, greater involvement in research planning, and improvements to the primary care setting to encourage willingness to participate in Innovation Fund projects amongst general practitioners.

Recruiting general practitioners and older patients with multimorbidity to randomized trials

BACKGROUND

Older patients with multimorbidity are under-represented in experimental research.

OBJECTIVE

To explore the barriers and facilitators to general practitioner (GP) and older patient recruitment and retention in a cluster randomized controlled trial (RCT).

METHOD

This descriptive study uses qualitative and quantitative data from a cluster RCT, designed to evaluate the effectiveness of a medicines optimization intervention. The SPPiRE cluster RCT enrolled 51 general practices and 404 patients aged ≥65 years and prescribed ≥15 medicines. Quantitative data were collected from all recruited practices and 32 additional practices who were enrolled, but unable to recruit sufficient participants. Qualitative data were collected from purposive samples of intervention GPs (18/26), patients (27/208), and researcher logs and analysed thematically using inductive coding.

RESULTS

Enrolment rates for practices and patients were 37% and 25%, respectively. Barriers to GP recruitment were lack of resources and to patient recruitment were difficulty understanding trial material and concern about medicines being taken away. GPs' primary motivation was perceived importance of the research question, whereas patients' primary motivation was trust in their GP. All general practices were retained. Thirty-five patients (8.6%) were lost to follow-up for primary outcomes, mainly because they had died and 45% did not return patient-reported outcome measures (PROMs).

CONCLUSION

Patient retention for the primary outcome was high, as it was collected directly from patient records. Patient completion of PROM data was poor, reflecting difficulty in understanding trial material. Recruiting older patients with multimorbidity to clinical trials is possible but requires significant resource and planning.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12752680.

An innovative approach to recruiting participants for dementia research: primary care and researcher perspectives

Aim: To describe clinician and researcher perceptions of a new, patient preference focused approach to recruiting patients for research from primary care-based memory clinics. Methods: Memory clinic clinicians completed a survey and key informants completed an individual interview to gather their perceptions of this new program. Results: The majority of clinicians were 'satisfied' or 'very satisfied' with this recruitment approach and indicated that this approach would have minimal negative impact on patient care or create conflict of interest. Key informants valued the program for its patient-centred approach, the integration of research into care and potential for increased recruitment. Discussion: These findings are suggestive of support for this recruitment approach. Pilot testing will inform feasibility, effectiveness and process improvements.

Optimising recruitment in clinical trials for progressive multiple sclerosis: observational analysis from the MS-SMART and MS-STAT2 randomised controlled trials

BACKGROUND

Slower than planned recruitment is a major factor contributing to the delay or failure of randomised controlled trials to report on time. There is a limited evidence base regarding the optimisation of recruitment strategies. Here we performed an observational review of our experience in recruitment for two large randomised controlled trials for people with secondary progressive multiple sclerosis. We aimed to explicitly determine those factors which can facilitate trial recruitment in progressive neurodegenerative disease.

METHODS

Recruitment data from the sequential MS-SMART [NCT01910259] and MS-STAT2 [NCT03387670] UK randomised controlled trials was reviewed from the largest recruiting site, University College London (UCL). The trial population was similar which allowed comparison over the two recruitment periods of 2015-2016 and 2018-2021. This included sources of referral, progress through stages of recruitment, reasons for participant ineligibility and the impact of publicity events upon recruitment.

RESULTS

In MS-SMART, 18% of patients contacted were enrolled, compared to 27% for MS-STAT2. Online registration of interest portals provided the greatest number of referrals (76% in MS-SMART, and 51% in MS-STAT2), with publicity in national media outlets producing a demonstrable increase in the number of potential participants. The introduction of an online self-screening questionnaire for MS-STAT2 resulted in 67% of potential participants (3080 of 4605) automatically determining their own ineligibility. In both studies, however, around 60% of those directly telephoned to discuss the study were not eligible, with difficulties related to travel to trial visits, or excluded medication, being the most common issues. Eighty-four percent of those deemed potentially eligible following telephone calls were enrolled in the MS-STAT2 study, compared to only 55% for MS-SMART.

CONCLUSIONS

Through a detailed review of recruiting participants at the largest centre into two large randomised controlled trials with similar entry criteria, we have identified a number of approaches that may improve recruitment efficiency. We highlight here the importance of mandatory online self-screening questionnaires, a coordinated publicity campaign, and simple interventions such as eligibility checklists and appointment reminders. Recruitment approaches should be further assessed through a studies within a trial (SWAT) design.

TRIAL REGISTRATION

MS-SMART: NCT01910259 ; registered July 2013 and MS-STAT2: NCT03387670 ; registered Jan 2018.

[The German Innovation Fund and primary care-What expectations and experiences do general practitioners have with regard to participating in innovative care models?]

BACKGROUND

In 2015, the German Innovation Fund was established to promote improvements in the quality of medical care. In order for new care models and interventions to be tested and incorporated into standard care in the future, primary care must be included.

OBJECTIVES

The study explores general practitioners' (GPs') attitudes, participation-relevant expectations, and experiences with regard to Innovation Fund projects.

METHODS

Between July and October 2021, all 13,170 general practitioners in Baden-Württemberg, Hesse, and Rhineland-Palatinate were invited to take part in an online survey. Included in the evaluation were 3556 completed questionnaires (response rate: 27%). In addition to the descriptive analysis, a t-test on independent samples was used to determine significant differences between two groups.

RESULTS

Of the respondents, 83% were familiar with the Innovation Fund. Most of the respondents associate it with opportunities and potential (including intensification of application-oriented healthcare research, independent financing, and inclusion of primary care). Nevertheless, many GPs are unsure to what extent primary care can benefit from the Innovation Fund in the longer term. When it comes to willingness to participate in Innovation Fund studies, the respondents are divided. Respondents who have already participated in such projects (24%) draw a positive balance (benefit of the intervention, cost-benefit ratio). However, hurdles and stress factors are also reported, such as documentation requirements and interventions in practice processes.

CONCLUSIONS

In order to increase the attractiveness of the Innovation Fund for GPs, it is important to ensure that projects are fully compliant with primary care, especially with regard to the scope of medical decision-making, the limitation of documentation obligations, the guarantee of practice routines, a greater involvement in research planning, and an upgrading of the GP setting.

Dementia care and the role of guideline adherence in primary care: cross-sectional findings from the DemTab study

Background

General practitioners (GPs) play a key role in the care of people with dementia (PwD). However, the role of the German Dementia Guideline in primary care remains unclear. The main objective of the present study was to examine the role of guideline-based dementia care in general practices.

Methods

A cross-sectional analysis of data obtained from the DemTab study was conducted. Descriptive analyses of sociodemographic and clinical characteristics for GPs (N = 28) and PwD (N = 91) were conducted. Adherence to the German Dementia Guideline of GPs was measured at the level of PwD. Linear Mixed Models were used to analyze the associations between adherence to the German Dementia Guideline and GP factors at individual (age, years of experience as a GP, frequency of utilization of guideline, perceived usefulness of guideline) and structural (type of practice, total number of patients seen by a participating GP, and total number of PwD seen by a participating GP) levels as well as between adherence to the German Dementia Guideline and PwD’s quality of life.

Results

Self-reported overall adherence of GPs was on average 71% (SD = 19.4, range: 25–100). Adherence to specific recommendations varied widely (from 19.2 to 95.3%) and the majority of GPs (79.1%) reported the guideline as only partially or somewhat helpful. Further, we found lower adherence to be significantly associated with higher numbers of patients (γ10 = − 5.58, CI = − 10.97, − 0.19, p = .04). No association between adherence to the guideline and PwD’s quality of life was found (γ10 = −.86, CI = − 4.18, 2.47, p = .61).

Conclusion

The present study examined the role of adherence to the German Dementia Guideline recommendations in primary care. Overall, GPs reported high levels of adherence. However, major differences across guideline recommendations were found. Findings highlight the importance of guidelines for the provision of care. Dementia guidelines for GPs need to be better tailored and addressed. Further, structural changes such as more time for PwD may contribute to a sustainable change of dementia care in primary care.

Trial registration

The DemTab trial was prospectively registered with the ISRCTN registry (Trial registration number: ISRCTN15854413). Registered 01 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02650-8.

What factors influence nursing home use of hospital avoidance programs? An interview study

AIMS

To understand why some nursing homes use hospital avoidance programs more frequently than others.

DESIGN

Two hospital avoidance programs, called residential-in-reach services in Victoria, Australia, were evaluated using a qualitative descriptive design.

METHODS

Between 2014 and 2018, 127 semi-structured interviews were conducted with staff from nursing homes, general practitioners and staff from the residential-in reach services. The interviews took an average of 45 min and transcripts were thematically analysed.

RESULTS

Nursing home reliance on residential-in-reach services to manage deteriorating residents was evident in both evaluations. Irrespective of the model of service provision, reliance was associated with: the increased care needs of residents; difficulties accessing timely and appropriate medical care; and the reduced numbers of skilled registered nurses to assess and manage deteriorating residents.

CONCLUSION

The residential-in-reach services are highly regarded by nursing homes. However, some are reliant on these services to provide nursing assessment and management. Using residential-in-reach services to substitute for nursing care, deskills nurses and shifts the cost of providing care from the service provider to other agencies. To provide residents with quality nursing care, the number of skilled registered nurses able to work within their scope of practice needs to be increased in Australian nursing homes.

IMPACT

The findings highlight the challenges of providing care in older people living in aged care. Increasing the number of skilled registered nurses in Australian nursing homes, would support deteriorating residents to stay in familiar surroundings and reduce reliance on external services to provide nursing care.