Learning from the implementation of a quality improvement intervention in Australian general practice: a qualitative analysis of participants views of a CVD preventive care project

Background

Quality improvement collaborative projects aim to reduce gaps in clinical care provided in the healthcare system. This study evaluated the experience of key participants from a Quality Improvement Program (QPulse) that focussed on cardiovascular disease assessment and management. The study goal was to identify critical barriers and factors enabling the implementation of a quality improvement framework in Australian general practice.

Methods

This qualitative study examined in-depth semi-structured interviews with nineteen purposively-selected participants of the QPulse project. Interviewees were from General Practices and the local supporting organisation, a Primary Health Network. Interviews were analysed thematically using the Complex Systems Improvement framework, focusing on five domains: strategy, culture, structure, workforce and technology.

Results

Despite reported engagement with QPulse objectives to improve cardiovascular preventive care, implementation barriers associated with this program were considerable for all interviewees. Adoption of the quality improvement process was reliant on designated leadership, aligned practice culture, organised systems for clear communication, tailored education and utilisation of clinical audit and review processes. Rather than practice size and location, practice culture and governance alignment to quality improvement predicted successful implementation. Financial incentives for both general practice and the Primary Health Network were also identified as prerequisites for systematised quality improvement projects in the future, along with individualised support and education for each general practice. Technology was both an enabler and a barrier, and the Primary Health Network was seen as key to assisting the successful utilisation of the available tools.

Conclusions

Implementation of Quality Improvement programs remains a potential tool for achieving better health outcomes in General Practice. However, enablers such as financial incentives, individualised education and support provided via a supporting organisation, and IT tools and support are crucial if the full potential of Quality Improvement programs are to be realised in the Australian healthcare setting.

Trial registration

ACTRN12615000108516, UTN U1111-1163–7995.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01692-0.

Simulation modelling as a tool for knowledge mobilisation in health policy settings: a case study protocol

BACKGROUND

Evidence-informed decision-making is essential to ensure that health programs and services are effective and offer value for money; however, barriers to the use of evidence persist. Emerging systems science approaches and advances in technology are providing new methods and tools to facilitate evidence-based decision-making. Simulation modelling offers a unique tool for synthesising and leveraging existing evidence, data and expert local knowledge to examine, in a robust, low risk and low cost way, the likely impact of alternative policy and service provision scenarios. This case study will evaluate participatory simulation modelling to inform the prevention and management of gestational diabetes mellitus (GDM). The risks associated with GDM are well recognised; however, debate remains regarding diagnostic thresholds and whether screening and treatment to reduce maternal glucose levels reduce the associated risks. A diagnosis of GDM may provide a leverage point for multidisciplinary lifestyle modification interventions. This research will apply and evaluate a simulation modelling approach to understand the complex interrelation of factors that drive GDM rates, test options for screening and interventions, and optimise the use of evidence to inform policy and program decision-making.

METHODS/DESIGN

The study design will use mixed methods to achieve the objectives. Policy, clinical practice and research experts will work collaboratively to develop, test and validate a simulation model of GDM in the Australian Capital Territory (ACT). The model will be applied to support evidence-informed policy dialogues with diverse stakeholders for the management of GDM in the ACT. Qualitative methods will be used to evaluate simulation modelling as an evidence synthesis tool to support evidence-based decision-making. Interviews and analysis of workshop recordings will focus on the participants' engagement in the modelling process; perceived value of the participatory process, perceived commitment, influence and confidence of stakeholders in implementing policy and program decisions identified in the modelling process; and the impact of the process in terms of policy and program change.

DISCUSSION

The study will generate empirical evidence on the feasibility and potential value of simulation modelling to support knowledge mobilisation and consensus building in health settings.

Evidence valued and used by health promotion practitioners

The use of evidence has become a foundational part of health promotion practice. Although there is a general consensus that adopting an evidence-based approach is necessary for practice, disagreement remains about what types of evidence practitioners should use to guide their work. An empirical understanding of how practitioners conceptualize and use evidence has been lacking in the literature. In this article, we explore (i) practitioners' purposes for using evidence, (ii) types of evidence they valued, and (iii) qualities that made evidence useful for practice. 58 semi-structured interviews and 250 h of participant and non-participant observation were conducted with 54 health promotion practitioners working across New South Wales, Australia. Interviews were recorded and transcribed, and field notes were written during the observations; these were analysed using Grounded Theory methods. Practitioners used evidence for practical and strategic purposes, and valued four different types of evidence according to their relevance and usefulness for these purposes. Practitioners' ideal evidence was generated within their practice settings, and met both substantive and procedural evaluation criteria. We argue that due to the complex nature of their work, practitioners rely on a diverse range of evidence and require organizational structures that will support them in doing so.

Cancer screening

"Screening is the systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to benefit from further investigation or direct preventive action, among persons who have not sought medical attention on account of symptoms of that disorder."

Criteria for evaluating evidence on public health interventions

Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.

Ethics and evidence-based medicine

Concerns about the ethics of evidence-based medicine (EBM) relate to possible alterations in the humane basis of clinical care. In collecting the evidence for EBM, scientists and doctors, not consumers, determine research objectives, interpret the data and implement the findings, and in doing so may disregard patients' priorities. Ethical standards, and what counts as evidence, are determined by socially or commercially powerful groups connected to powerful institutions. Such groups can generate evidence and determine "gold standard" knowledge, filtering out other, "inferior" knowledge. Applying the available evidence to predicting outcomes for individual patients involves uncertainty. Full disclosure of this uncertainty is a component of informed consent, but requires sensitivity to patients' tolerance of ambiguity. Ongoing debate about the ethics of EBM on all levels will ensure that EBM manifests intended and preferred social values and takes its rightful place in the practice of medicine and the development of health policy.

Lessons from a review of publications in three health promotion journals from 1989 to 1994

A thematic analysis was undertaken of 72 editorials in three leading health promotion journals, Health Education Research: Theory & Practice, Health Education Quarterly and Health Promotion International, from 1989 to 1994. The three main themes which emerged were (1) the need to broaden health promotion interventions, (2) the need to promote rigour and professionalism in the discipline of health promotion, and (3) the need to respond to the information requirements of practitioners. Against this context, we conducted a content analysis of the journals, examining the nature of the 649 peer-reviewed publications in the same time period. Categories from the traditional bio-medical 'stages of research' models had to be adapted before full classification of articles published was feasible. The largest number of articles published could be termed descriptive research, followed by studies developing and validating health promotion measurement tools and health promotion theory. The proportion of program evaluations was small and the proportion of randomized controlled trials ('highest quality evidence' of effectiveness) decreased over time. Dissemination studies were also poorly represented in spite of this being identified in editorials as an important professional need. Ways to redress some of the imbalances observed are discussed.