Reducing inappropriate hypnotic prescribing using a quality improvement initiative in a rural practice

Context This improvement project was set in a single general practice in rural Lincolnshire, East Midlands, UK. All doctors and practice staff were actively engaged in reducing inappropriate long term prescribing of hypnotic drugs in the practice population as part of a Quality Improvement Collaborative (QIC). Problem Hypnotic drugs are only licensed for short term use but inappropriate long-term prescribing of hypnotics is common. Evidence from previous studies shows that hypnotics have limited therapeutic value and potential for significant adverse cognitive and psychiatric effects. Although there is evidence for hypnotic drug withdrawal programmes there have been few improvement projects showing whether and how this might work in practice. Assessment of problem and analysis of its causes Baseline rates of hypnotic prescribing were analysed and charted using statistical process control (SPC) methods. Patients on repeat prescriptions of hypnotic drugs were identified from the practice database. Causes, solutions and barriers were determined using surveys and focus groups of patients and staff. A withdrawal programme was implemented for all patients on long term hypnotics by writing to patients, arranging a consultation, making a detailed assessment and using techniques such as tapering doses of drugs and using cognitive behavioural therapy for insomnia (CBTi) during general practice consultations. The improvement was supported by a QIC called REST (Resources for Effective Sleep Treatment) which supported the practice team to implement sleep assessment and management tools using plan-do-study-act cycles, process mapping and new protocols. Strategy for change The change was coordinated in the practice over six months, with each practitioner maintaining an agreed and consistent approach for managing sleep problems. All staff including doctors, nurses, administrative staff and practice manager took part. Patients were informed of the planned alteration to their treatment for their sleeping problem via a letter detailing exactly how the new regime would be implemented alongside the reasons for this. Patients were offered an appointment to discuss the proposed changes with their GP and all did so. Measurement of improvement We measured improvement by analysing prescribing rates using statistical process control charts. We also surveyed patients and conducted a focus group to explore the patients’ personal experiences of the new service the support they received during the withdrawal programme and how they manage their sleep now. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines (664.9 to 62.0 ADQ per 1000-STAR-PU) and Z drugs (2156.7 to 120.1A ADQ per STAR-PU) in the practice over the six months of the project and this improvement has been sustained since the initiative. Some patients were initially unhappy about being taken off sleeping tablets but with the approach described were successfully withdrawn. No patients are now prescribed long term benzodiazepines or Z drugs for sleep difficulties in the practice. Psychological treatments for the management of sleep problems are used first-line instead of hypnotics. The transition from hypnotics to psychological treatments is evidence of improvement in patient care. Lessons learnt It is possible to implement a hypnotic withdrawal programme over a relatively short period of time in general practice using a carefully constructed programme applied consistently by staff comprising a letter to patients, tapering of drugs and CBTi supported through education of practitioners in sleep management and quality improvement methods. Message for others Key factors for success in this improvement project were a motivated practice team, a range of solutions which could be adapted locally, expert support on sleep management and quality improvement methods and feedback of results. We will present further data on the experience of patients in this improvement project

Using mixed methods for evaluating the effect of a quality improvement collaborative for management of sleep problems presenting to primary care

Context This improvement project was set in Lincolnshire, a large rural county in the East Midlands with high prescribing rates of hypnotic drugs compared with the rest of England. Eight general practices volunteered to participate in a Quality Improvement Collaborative (QIC) designed to improve management of sleep problems in patients presenting to primary care. Problem Sleep problems are common affecting around 40% of adults in the UK. Insomnia has considerable resource implications in terms of disability, impaired quality of life and health service utilisation. Up to half of individuals with Insomnia seek help from primary care and hypnotic drugs are often inappropriately prescribed for long term use. Non-pharmacological treatment measures are rarely implemented in practice despite guidance supporting their use. A lack of training as well as limited availability of resources for effective sleep assessment and treatment in primary care are possible explanations for this. It is clear that there is considerable scope for improving management of sleep problems in general practice Assessment of problem and analysis of its causes We used a Quality Improvement Collaborative to introduce practitioners to sleep assessment tools including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI) and Sleep Diaries and non-pharmacological interventions such as Cognitive Behavioural Therapy for Insomnia (CBTi). Practitioners from participating practices were asked to begin using these where appropriate within their day to day practice. Strategy for change The project team met bi-monthly with practice teams to share learning. We used adult learning techniques to promote rapid experimentation (Plan, Do, Study, Act) cycles, process redesign and monthly feedback of prescribing rates and costs of hypnotic drugs using statistical control charts. Data were collected from the collaborative meetings to understand the facilitators, barriers and changes that practices were making as a result of the Quality Improvement Collaborative (QIC). Measure of improvement Qualitative data were collected via audio recordings of practice and collaborative meetings with practitioners and practice staff. This data was then transcribed verbatim. Thematic analysis was carried out supported by computer software MaxQDA using a framework method. Nine themes emerged which were then reviewed by five members of the evaluation steering group to assess inter-rater reliability of the themes. We used statistical process control charts and an interrupted time series design to analyse prescribing data for the two year period preceding the establishment of the collaborative and for the six months of its operation. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines and Z drugs in the practices over the six months of the project and this improvement has been sustained since the initiative. Nine themes emerged from the qualitative data: - Engagement of staff: Most practitioners showed enthusiasm to incorporate changes in their practice and encouraged other members of the practice to become involved by demonstrating use of the tools and reminders during meetings “It’s brought up at every practice meeting and so it’s always fresh in people minds. It’s not something that’s then forgotten.” Practitioner views of the tools: Practitioners tried the tools and techniques and overall seemed to favour the Sleep diary and Insomnia Severity Index (ISI) over the Pittsburgh Sleep Quality Index (PSQI) “Generally we found that the ISI was easy to complete, score and interpret and can be used in general practice” Practitioner preconceptions: Practitioners came with preconceptions about the feasibility of sleep tools and techniques. Patients’ age and intellect were factors that practitioners thought might affect whether tools were completed correctly or at all. Needs & educational needs of patients & staff: Before this project hypnotics had been seen as the solution to most sleep problems by both patients and practitioners. “When people come in it was so easy to give them a prescription” "As GPs we’re overly limited and actually to have a slightly more sophisticated response would actually be better for us but also for the patient”. Barriers to implementing tools & techniques: This related to systems (of care) practitioners and patients Systems: “Once the psychiatrist says you should have this, it is really hard as a GP to go against it because you know they say the psychiatrist has asked me to take this.” Practitioner: “We come down to the cognitive behaviour therapy approach; it’s a bit thin on my part, we’ve not got great skills in that”. Patient: “I think the key is also definitely how to communicate it…the minute you start even trying to approach the subject that the tablets are not really very good and what about thinking about alternative ways, they will kind of glare very rudely and be like I have been there before doc[tor]. So you have got to kind of approach it in a kind of a fresh way to make them thing they are trying something new. You have got to be a salesman’. Changes initiated by practices: Some practices had taken other measures to try and reduce hypnotic prescribing including implementing withdrawal programmes and limiting repeat prescriptions which let to improvement is patient and practitioner experience GP-Patient treatment & expectations: Practitioners revealed what they thought patients expected and made suggestions of how consultations could be improved to meet patients’ needs and increase successful outcomes from a sleep consultation. Importance of tailored approach: Each patient with Insomnia would need to have their treatment tailored to their individual requirements therefore every consultation could potentially have very different solutions Lack of feedback from patients: Receiving feedback from patients was difficult for some practitioners when patients didn’t return for their follow-up consultation or didn’t complete and return their sleep assessment tools. This lead practitioners to feel unsure as to whether patients had read and absorbed the information provided to them Lessons learnt Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care and patient and practitioner experience Message for others Quality improvement collaboratives benefit from careful analysis using qualitative as well as quantitative methods. Further information www.restproject.org.uk Project manager: [email protected] Project lead: [email protected]

A case study approach to understand how quality improvement methods led to improvements in primary care for insomnia

Context: The Resources for Effective Sleep Treatment (REST) project was conducted in Lincolnshire, UK from 2007-2010. Its aim was to develop and evaluate new approaches to implementing sleep assessment methods and non-pharmacological treatments for insomnia into routine general practice. Problem: Sleep problems are common affecting 30% of the population in the previous year. Many insomnia sufferers present to general practice but patients and clinicians feel that primary care management should be improved. For example, there is considerable evidence of underuse of sleep assessment tools and psychological treatments such as cognitive behavioural therapy for insomnia (CBTi), continuing evidence of inappropriate long term prescribing of hypnotics and a perception of poor practice among patients and practitioners. Assessment of problem and analysis of its causes: Multiple mixed methods including surveys, qualitative analysis (of focus groups, interviews, practice visits and collaborative meetings) and analysis of prescribing data were used to understand the problem of sleep management and how to improve it. Intervention: We used a series of collaboratives to develop and spread the intervention. The initial modelling collaborative was used to develop a multidisciplinary model for management of sleep problems in primary care: ‘problem focused therapy’. This uses careful assessment using sleep diaries and sleep assessment tools and treatment using modified CBTi for insomnia. A subsequent collaborative was used to spread the intervention more widely. Study design: We used a multiple case study approach to develop an explanatory model of why and how GPs engaged to improve sleep management in the ‘modelling’ and ‘spread’ collaboratives. Using practices as the units of analysis we describe how clinicians (re)framed the problem, developed solutions and saw the impact of these on changing practice. Strategy for change: We used a range of multidisciplinary team approaches to understand the need for and receptiveness to change, how change could be introduced and how these changes in management of sleep problems could be spread more widely during the project and beyond. Measurement of improvement: We used qualitative and time series methods to show changes in care over time. We gathered evidence on what care patients currently received and what they needed, how practitioners responded and how they could change practice and how practice teams redesigned processes of care and the impact of these changes on quality of care and prescribing for sleep problems. Effects of changes: within two years, over one third of practices (36/102) in the county had participated in the quality improvement project with evidence of change in clinical routines, benefits to patients’ experiences of care and significant reductions in prescribing in some practices. Lessons learnt: Quality improvement projects which require introduction of new health technologies require different collaborative approaches to developing new models of care, compared to projects which are trying to improve the reliability of care or to spread knowledge. Message for others: Case study methods provided an invaluable way to understand the complex ‘black box’ of quality improvement to show how patients and practitioners adopted and benefited from improved systems of care for insomnia

Designing an intervention for improving primary care management of sleep problems (REST: Resources for Effective Sleep Treatment)

Brief outline of context An improvement project was begun in a Primary Care Trust in Lincolnshire a large rural county in the East Midlands of the United Kingdom comprising almost 700,000 patients. The projects included patients, general practitioners and their primary care teams, pharmacists and research and audit teams. Brief outline of problem Hypnotic prescribing rates from general practice Prescribing Analysis and Cost Data was identified by the executive as high in Lincolnshire compared to the rest of the East Midlands and the United Kingdom. Published research has shown that the clinical benefits of hypnotic drugs are small with significant risks of complications from adverse cognitive, psychiatric or psychomotor effects which may persist for several months after stopping the drug. The extent of the problem, its nature and the barriers to improvement were not well understood given that previous attempts to improve prescribing rates in this area of practice had failed. Assessment of problem and analysis of its causes Previous efforts to improve this aspect of quality and safety in healthcare in Lincolnshire and nationally have been hampered because of practitioner and patient attitudes, lack of organisational support or systems for change and an emphasis on other areas of healthcare. To understand the barriers to improving prescribing more fully we used questionnaires to general practitioners and patients and measured variation in prescribing rates across practices. Unforeseen and hitherto invisible problems were revealed by the responses. In addition, the views of patients prescribed hypnotics in the previous six months exposed high rates of inappropriate long term prescribing (94.9%had taken benzodiazepine or Z drug hypnotics for four weeks or more), side effects (41.8%reported at least one side effect), a wish to stop taking drugs (Z-drugs vs. benzodiazepines: 22.7 vs. 12.3%; p=0.001) and previous attempts by patients to come off medication (Z-drugs vs. benzodiazepines: 52.4% vs. 41.0%; p=0.001). Potential barriers to improvement included attitudes of general practitioners which supported prescribing of newer (Z drug) hypnotics for the majority of indications. More positively, practitioners were aware of their practice prescribing rates to the extent that they were able to identify whether they were in a high, intermediate or low prescribing practice. Most doctors held a negative perception of hypnotics and were positive to the idea of reducing prescribing in this area. Practitioners’ favoured methods for reducing prescribing helped inform potential strategies for change and will be presented. On the basis of these results it was felt that systematic efforts at implementation and improvement were likely to be successful given appropriate organisational support from the Primary Care Trust. Strategy for change: How did you implement the proposed change? What staff or other groups were involved? How did you disseminate the results of your analysis and your plans for change to the groups involved with/affected by the planned change? What was the timetable for change? A change project was developed, Resources for Effective Sleep Treatment (REST), with a number of stakeholders including partner organisation and patients. The aims of this project are to produce measurable improvements in the management of insomnia, specifically to: a. Reduce rate and (costs) of z-drug prescribing by 50% in 3 years b. Reduce the rate (costs) of benzodiazepine hypnotic prescribing by 25% in 3 years c. Increase use of recorded non-pharmacological measures in insomnia by at least 100% in 3 years. d. Improve the user experience of management of insomnia. We will use evidence based methods to develop an effective spread and adoption strategy to effect a sustained and sustainable change in practice in relation to management of insomnia. We will initially work with 10 pilot practices (10% of the total) using rapid experimentation (plan, do, study, act) cycles. We plan to work with these willing adopter practices and practitioners to develop a network of good practice, measurement and improvement tools, opinion leaders and champions for good practice using rapid cycle of change. We will also undertake focus groups with prescribing practitioners and patients to help understand more fully the barriers and facilitators, to identify good practice and to design appropriate improvement methods and interventions in this area of practice. Tailored interventions for practices involving clinician, pharmacy, secondary care and administrative support could help bring about change in clinical management. Measurement of improvement We will gather and analyse prescribing and improvement data from all practices in the county to enable systematic spread and adoption of improvements in prescribing and improvement methods more generally in the county. Lessons learned This project has emphasised the importance of gathering data at the onset of quality improvement initiatives to understand invisible barriers or facilitators for change and of involvement of patients and practitioners in their initial and ongoing development. Message for others Quality improvement projects benefit from research as well as quality improvement expertise in order to analyse, present and utilise information for their appropriate design

Patient experiences of a quality improvement initiative to reduce inappropriate long term hypnotic prescribing in a rural practice

Introduction Insomnia is common affecting up to 40% of adults. About a half of sufferers seek help from primary care, usually receiving sleep hygiene advice or hypnotic medication. Hypnotics are licensed short term, have limited therapeutic value and significant potential adverse effects, but many patients continue to receive them long term inappropriately. An innovative sleep management programme to reduce inappropriate prescribing of hypnotics was implemented by a single general practice in rural Lincolnshire as part of a quality improvement collaborative. This involved gradual withdrawal of hypnotic drugs supported by sleep assessment and treatment using cognitive behavioural therapy for insomnia. Little is known about patients’ experience of this type of withdrawal programme. We aimed to investigate patients’ experiences. Method We used a focus group interview to investigate patients’ experiences of the programme, inviting patients who had undergone the programme by letter. The focus group was moderated by two independent non-clinical researchers using a topic guide. Data were recorded, transcribed and analysed using a constant comparative approach using MAXQDA 2007. Results A single focus group was held with four patients. Key themes that emerged included current feelings about sleeping tablets, attitudes towards the process, access to GP support, perceived usefulness of sleep management, (re)attribution of sleep difficulty and current quality of patients’ sleep. Although patients were initially ambivalent they followed the programme because of trust in their doctor and a clear and consistent approach from the practice. Patients expressed a need for more face-to-face sleep advice during the process and greater recognition afterwards. They were generally positive about the benefits of hypnotic withdrawal despite variable effects on sleep. Discussion Patients were positive about the benefits of withdrawing from long term hypnotic drugs. They made recommendations about future programmes. Sleep education should be delivered during a consultation and a formal end to the process, recognising the patients’ success, should be incorporated. The main limitation was that the focus group was conducted over a year after the sleep management programme was conducted which may have affected participation. Focus groups can provide a useful method of evaluating patients’ experience which is an important aspect of quality of care

Effectiveness of an educational intervention for general practice teams to deliver problem focused therapy for insomnia: pilot cluster randomised trial

Introduction Sleep problems are common leading to physical and psychosocial morbidity and impaired quality of life. Sufferers often seek help from primary care and receive advice or hypnotic drugs which are ineffective long term. Cognitive behavioural therapy for insomnia (CBTi) is effective but is not widely used in general practice. We conducted a pilot study to test procedures and collect information in preparation for a larger definitive trial to measure effectiveness and cost-effectiveness of an educational intervention for general practitioners and primary care nurses a to deliver problem focused therapy to adults Methods This was a pilot cluster randomised controlled trial. General practices were randomised to an educational intervention (2x2 hours) for problem focused therapy which comprised assessment (of secondary causes, severity and using sleep diaries) and modified CBTi compared with usual care (sleep hygiene advice and hypnotic drugs). We recruited patients with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety and Pittsburgh Sleep Quality Index (PSQI≥4). The primary outcome was PSQI and secondary outcomes including Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Beck Depression Inventory and PSYCHLOPS were measured at 0, 4, 8 and 13 weeks. Intervention fidelity was evaluated using telephone interviews of participating practitioners and patients. Results Out of 64 participants recruited, 37 completed the trial. Analysis was conducted masked to treatment allocation. We used a mixed effects model to test for overall change and whether the intervention affected the rate of change over time. There was significant dropout during the pilot study, mainly due to delays in recruitment. We detected neither an overall change over time (PSQI score increase per week 0.06 (95%CI -0.03 to 0.16) nor differential change between intervention and control groups 0.10 (-0.03 to 0.23) although the study was not powered to detect such a change. Conclusion This pilot study confirmed that it was feasible to undertake a trial of education for primary care clinicians to deliver problem focused therapy for insomnia in general practice but also exposed problems with study recruitment, dropout, and intervention fidelity which should be addressed in the design of a full trial

Resources for Effective Sleep Treatment (REST): case study of engaging general practice teams to improve the quality of care for patients presenting with sleep problems

Introduction Sleep problems are common with perceptions that management should be improved in general practice. There is considerable evidence of underuse of sleep assessment tools and psychological treatments such as cognitive behavioural therapy for insomnia (CBTi), continuing evidence of inappropriate long term prescribing of hypnotics and a perception of poor practice among patients and practitioners. The Resources for Effective Sleep Treatment (REST) project aimed to study new approaches and models for implementing sleep assessment methods and CBTi into routine practice in a large rural county as part of a wider quality improvement programme. Method We used a multiple case study approach and logic model to describe how we approached the problem of engaging general practitioners in improving sleep management. Using practices as the units of analysis we describe how we (re)framed the problem, developed solutions and saw the impact of these on changing practice. We used qualitative and time series analysis of prescribing to show changes in care over time. Results Within two years of starting, over one third of practices had participated in the quality improvement project with evidence of change in routines in some practices. We gathered evidence on what care patients currently received and what they needed, how practitioners responded and how they could change practice, how practice teams redesigned processes of care and the impact of these changes on quality of care and prescribing for sleep problems. Discussion We used a range of approaches to understand the need for and receptiveness to change in management of sleep problems, how change could be introduced into general practice and how these changes could be spread more widely. Potential problems of generalisability were addressed through triangulating evidence. An approach using multiple methods sequentially and concurrently, to understand the problem of sleep management and how to improve it, has helped inform development of a multidisciplinary model for management of sleep problems in primary care. ‘Problem focused therapy’ uses a consultation approach comprising careful assessment and use of modified CBTi for insomnia, which if adopted more widely will potentially improve the quality of patient care in the primary care treatment of insomnia

Qualitative study of the effect of a quality improvement collaborative for better management of sleep problems presenting to primary care

Introduction Sleep problems are common with scope for improving sleep management in general practice. There is considerable evidence of inappropriate long term prescribing of hypnotics and underuse of psychological treatments such as cognitive behavioural therapy for insomnia (CBTi). We aimed to investigate practitioners’ experience of the feasibility and practicability of implementing sleep assessment tools and non-pharmacological interventions for sleep management in primary care. Method We set up a Quality Improvement Collaborative (QIC) with eight general practices in Lincolnshire, East Midlands, UK as part of the Resources for Effective Sleep Treatment (REST) project to study potential new approaches for implementing sleep assessment methods and CBTi in practice. The project team met monthly with practice teams to share learning about sleep management and data were collected using audiotapes to understand the facilitators, barriers and changes that practices were making as a result of the QIC. Audiotapes were transcribed verbatim and thematic analysis was carried out with the aid of MAXQDA. Results Meetings with each practice team (2 each) and the collaborative group (4) during the QIC were analysed. Nine themes emerged: engagement of staff, practitioner views of different tools, barriers to implementing the sleep tools and techniques, practitioner and patient preconceptions and expectations of treatment, educational and support needs of patients and staff, changes initiated/to be initiated by practices and the importance of a tailored approach. Discussion Practitioners’ preconceptions, attitudes, beliefs and educational needs needed to be addressed for successful implementation of sleep tools and techniques. Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care. A collaborative approach utilising quality improvement techniques informed development of an interdisciplinary model for management of sleep problems in primary care: ‘problem focused therapy’. This uses a consultation approach comprising careful assessment and use of modified CBTi for insomnia in the consultation, which is being investigated in an exploratory randomised controlled trial. If ‘problem focused therapy’ is successful then we expect a substantial improvement in the quality of patient care in the primary care treatment of insomnia

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

Background: Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design: This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion: Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation

Strategies for improving patient recruitment to focus groups in primary care: a case study reflective paper using an analytical framework

<p>Abstract</p> <p>Background</p> <p>Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care).</p> <p>Methods</p> <p>The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST) study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed.</p> <p>Results</p> <p>The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems.</p> <p>Conclusion</p> <p>We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.</p