Implementing quality improvement strategies in real-world general practice- a study focused on cardiovascular disease

Introduction General practitioners (GPs) are central to cardiovascular disease (CVD) prevention and management. However, multiple studies show they have sub-optimal assessment and management of CVD risk. The central question addressed in this thesis was: How do we translate preventive care guidelines into the real world of Australian general practice through Quality Improvement Collaboration (QIC)? Methods The research comprised of four studies. The first examined the experiences of stakeholders participating in a quality improvement collaboration (QIC) intervention undertaken in Australian primary care [the Australian Primary Care Collaboratives [APCC] program], and the second assessed implementation of the 2012 CVD risk management guidelines in Australian general practices. It examined electronic medical record data from 95 general practices comprising 102 225 patients. In the third and fourth studies, a QIC intervention [QPulse] focused on improving CVD risk management was implemented in 34 general practices, and its effectiveness, barriers and enablers were evaluated. Results There were substantial gaps in the implementation of CVD guidelines, which remained after the brief QIC intervention aimed at achieving improvements in CVD screening and management (QPulse). The qualitative evaluation interviews of stakeholders in the APCC and QPulse interventions highlighted that the Australian primary care environment is a complex and challenging setting to implement sustainable change, and obstacles at multiple levels impact the success of QI initiatives. Leadership, practice culture, access to accurate patient data and IT/practice support systems were elements required for the long-term adoption and implementation of systematic QI. Stakeholders identified two key factors that would assist Australian general practices to make QI sustainable: 7 practice support by an external support organisation and financial incentives for implementing QI programs. Discussion Significant gains in CVD morbidity and mortality could be achieved by improving CVD management in primary care. A ‘siloed’ QI program may not be effective, as there are several barriers to sustainable change. These are cultural factors, leadership and support systems to facilitate staff to implement QI. Additionally, QI programs need to be implemented with the assistance of an external agency to support practices, and incentives are required for practices and GPs to implement and sustain change. Conclusions CVD management in primary care has much scope for improvement, and QI is unlikely to address this effectively unless changes at the health system and practice levels alleviate key barriers. Future progress will require concerted efforts to realign the culture of primary healthcare and the practical and financial support provided to GPs and practices so that QI is valued and implemented in day-to-day patient management and the practice workflow

Informing implementation of quality improvement in Australian primary care

Background: Quality Improvement (QI) initiatives in primary care are effective at improving uptake of evidence based guidelines, but are difficult to implement and sustain. In Australia meso-level health organisations such as Primary health care Organisations (PHCO) offer new opportunities to implement area-wide QI programs. This study sought to identify enablers and barriers to implementation of an existing Australian QI program and to identify strategic directions that PHCOs can use in the ongoing development of QI in this environment. Methods: Semi-structured telephone interviews were conducted with 15 purposively selected program staff and participants from the Australian Primary Care Collaborative (APCC) QI program. Interviewees included seven people involved in design, administration and implementation of the APCC program and eight primary care providers (seven General Practitioners (GPs) and one practice nurse) who had participated in the program from 2004 to 2014. Interviewees were asked to describe their experience of the program and reflect on what enabled or impeded its implementation. Interviews were recorded, transcribed and iteratively analysed, with early analysis informing subsequent interviews. Identified themes and their implications were reviewed by a GP expert reference group. Results: Implementation enablers and barriers were grouped into five thematic areas: (1) leadership, particularly the identification and utilisation of change champions; (2) organisational culture that supports quality improvement; (3) funding incentives that support a culture of quality and innovation; (4) access to and use of accurate data; and 5) design and utilisation of clinical systems that enable and support these issues. In all of these areas, the active involvement of an overarching external support organisation was considered a key ingredient to successful implementation. Conclusion: There are substantial opportunities for PHCOs to play a pivotal role in QI implementation in Australia and internationally. In developing QI programs and policies, such organisations ought to invest their efforts in: (1) identifying and mentoring local leaders; (2) fostering QI culture via development of local peer networks; (3) developing and advocating for alternative funding models to support and incentivise these activities; (4) investing in data and audit tool infrastructure; and (5) facilitation of systems implementation within primary care practices

Screening for atrial fibrillation: The essential role of GPs

Asymptomatic atrial fibrillation (AF) is associated with similar stroke risk as symptomatic AF, yet is often detected only after the patient presents with a devastating stroke. The first Australian guidelines for the screening and management of AF were released in 2018 by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. This brief, practical summary of the guidelines focuses on screening in general practice

Reducing stroke risk in atrial fibrillation: Adherence to guidelines has improved, but patient persistence with anticoagulant therapy remains suboptimal.

Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians\u27 management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient\u27s factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician\u27s awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF

Consultation contexts and the acceptability of alcohol enquiry from general practitioners - a survey experiment

Background: General practitioners have a crucial role in detecting risky drinking in patients. However, little is known about how the context of the consultation affect patient acceptability of these discussions. Methods: During one week in May 2014, adult patients seen at a community general practice in Sydney were randomised to receive one of two postal questionnaires. Participants rated the acceptability of alcohol enquiry in 20 vignettes of general practice consultations, either within a SNAP (smoking, nutrition, alcohol, physical activity) framework (intervention) or alone (control). Results: Of the 441 patients who received the questionnaires, 144 returned completed and returned it. The intervention group rated an additional 2.1 (95% CI = 0.38-3.7, P = 0.016) vignettes as acceptable compared to the control group. Alcohol enquiry acceptability varied greatly between individual scenarios. Discussion: Alcohol-use assessment may be more acceptable to patients when it is framed within the SNAP framework, especially in certain presentations (eg diabetes management)

The Telehealth Skills, Training, and Implementation Project: An evaluation protocol

External stabilization is reported to improve reliability of hand held dynamometry, yet this has not been tested in burns. We aimed to assess the reliability of dynamometry using an external system of stabilization in people with moderate burn injury and explore construct validity of strength assessment using dynamometry. Participants were assessed on muscle and grip strength three times on each side. Assessment occurred three times per week for up to four weeks. Within session reliability was assessed using intraclass correlations calculated for within session data grouped prior to surgery, immediately after surgery and in the sub-acute phase of injury. Minimum detectable differences were also calculated. In the same timeframe categories, construct validity was explored using regression analysis incorporating burn severity and demographic characteristics. Thirty-eight participants with total burn surface area 5 – 40% were recruited. Reliability was determined to be clinically applicable for the assessment method (intraclass correlation coefficient \u3e0.75) at all phases after injury. Muscle strength was associated with sex and burn location during injury and wound healing. Burn size in the immediate period after surgery and age in the sub-acute phase of injury were also associated with muscle strength assessment results. Hand held dynamometry is a reliable assessment tool for evaluating within session muscle strength in the acute and sub-acute phase of injury in burns up to 40% total burn surface area. External stabilization may assist to eliminate reliability issues related to patient and assessor strength

In a large primary care data set, the CHA₂DS₂-VASc score leads to an almost universal recommendation for anticoagulation treatment in those aged ≥65 years with atrial fibrillation

From 2012 to 2016, the oral anticoagulant (OAC) treatment determination for atrial fibrillation (AF) patients moved from the CHADS2 score to the CHA2DS2-VASc score. A data set collated during previous studies (2011–19) with de-identified data extracted from clinical records at a single timepoint for active adult patients (n = 285 635; 8294 with AF) attending 164 general practices in Australia was analysed. The CHA2DS2-VASc threshold (score ≥2 men/≥3 women) captured a significantly higher proportion than CHADS2≥2 (all ages: 85 vs. 68%, P < 0.0001; ≥65 years: 96 vs. 76%, P < 0.0001). The change from CHADS2 to CHA2DS2-VASc resulted in a significantly higher proportion of AF patients being recommended OAC, driven by the revised scoring for age

Atrial Fibrillation Screen, Management And Guideline Recommended Therapy (AF SMART II) in the rural primary care setting: a cross-sectional study and cost-effectiveness analysis of eHealth tools to support all stages of screening

BackgroundInternationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people aged ≥65 years, and oral anticoagulant (OAC) treatment for those at high stroke risk (CHA₂DS₂-VA ≥2). However, gaps remain in screening and treatment.Methods and ResultsGeneral practitioners/nurses at practices in rural Australia(n=8) screened eligible patients (aged ≥65 years without AF) using a smartphone electrocardiogram during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted deidentified data. Results were compared to an earlier study in metropolitan practices(n=8) and non-randomised control practices(n=69). Cost-effectiveness analysis compared population-based screening to no screening and included screening, treatment and hospitalisation costs for stroke and serious bleeding events. Patients (n=3,103, 34%) were screened (mean age 75.1±6.8 years, 47% male) and 36(1.2%) new AF cases were confirmed (mean age 77.0 years, 64% male, mean CHA₂DS₂-VA=3.2). OAC treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen-detected) versus 74% (pre-existing AF)(p=NS), similar to metropolitan and non-randomised control practices. The incremental cost-effectiveness ratio (ICER) for population-based screening was AU$16,578/quality adjusted life year gained and AU$84,383/stroke prevented compared to no screening. National implementation would prevent 147 strokes/year. Increasing the proportion screened to 75% would prevent 177 additional strokes/year.ConclusionsAn AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. OAC treatment rates were relatively high at baseline, trending upwards during the study. Increasing the proportion screened would prevent many more strokes with minimal ICER change. eHealth tools, including data reports, may be a valuable addition to future programs

Atrial Fibrillation Screen, Management And Guideline Recommended Therapy (AF SMART II) in the rural primary care setting: an implementation study protocol

Introduction: Screening for atrial fibrillation (AF) in people ≥65 years is now recommended by guidelines and expert consensus. While AF is often asymptomatic, it is the most common heart arrhythmia and is associated with increased risk of stroke. Early identification and treatment with oral anticoagulants can substantially reduce stroke risk. The general practice setting is ideal for opportunistic screening and provides a natural pathway for treatment for those identified.This study aims to investigate the feasibility of implementing screening for AF in rural general practice using novel electronic tools. It will assess whether screening will fit within an existing workflow to quickly and accurately identify AF, and will potentially inform a generalisable, scalable approach.Methods and analysis: Screening with a smartphone ECG will be conducted by general practitioners and practice nurses in rural general practices in New South Wales, Australia for 3–4 months during 2018–2019. Up to 10 practices will be recruited, and we aim to screen 2000 patients aged ≥65 years. Practices will be given an electronic screening prompt and electronic decision support to guide evidence-based treatment for those with AF. De-identified data will be collected using a clinical audit tool and qualitative interviews will be conducted with selected practice staff. A process evaluation and cost-effectiveness analysis will also be undertaken. Outcomes include implementation success (proportion of eligible patients screened, fidelity to protocol), proportion of people screened identified with new AF and rates of treatment with anticoagulants and antiplatelets at baseline and completion. Results will be compared against an earlier metropolitan study and a ‘control’ dataset of practices.Ethics and dissemination Ethics approval was received from the University of Sydney Human Research Ethics Committee on 27 February 2018 (Project no.: 2017/1017). Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.Trial registration number ACTRN12618000004268; Pre-results

An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial

Background: Cardiovascular diseases (CVD) are responsible for significant morbidity, premature mortality, and economic burden. Despite established evidence that supports the use of preventive medications among patients at high CVD risk, treatment gaps remain. Building on prior evidence and a theoretical framework, a complex intervention has been designed to address these gaps among high-risk, under-treated patients in the Australian primary care setting. This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities; availability of a range of CVD polypills (fixed-dose combinations of two blood pressure lowering agents, a statin ± aspirin) for prescription when appropriate; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification. Methods: Following a systematic development process, the intervention will be evaluated in a pragmatic cluster randomized controlled trial including 70 general practices for a median period of 18 months. The 35 general practices in the intervention group will work with a nominated partner pharmacy, whereas those in the control group will provide usual care without access to the intervention tools. The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels at the study end. The outcomes will be analyzed using data from electronic medical records, utilizing a validated extraction tool. Detailed process and economic evaluations will also be performed. Discussion: The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients, pharmacists, and general practitioners (GPs) for CVD prevention. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN1261600023342