What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial
What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial
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DOI：
10.1136/bmjopen-2015-008480
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发表时间：
2016-01-01
期刊：
影响因子：
2.9
通讯作者：
Gallagher, Hugh
中科院分区：
文献类型：
--
作者：
Nihat, Akin;de Lusignan, Simon;Gallagher, Hugh
目的：本研究是对慢性肾脏病质量改善（QICKD）研究的过程评估，比较了基于网络的教育（ABE）和发送临床指南和提示（G&P）与常规实践，以改善初级保健中的收缩压控制。本评价旨在探讨参与实践的临床工作人员对干预措施的了解程度，以及为什么实践可能发生变化。设置：英格兰的4个初级保健实践：2个接受ABE，2个接受G& P。我们有目的地从每个研究组中选择1个北方/南方/城市和农村实践参与者：有目的地对4个研究实践进行抽样，并与每个实践的工作人员进行焦点小组。干预措施：在研究中期和研究结束时，在4个实践中的每一个实践中都有焦点小组。最初未选择用于深入过程评价的另外4个试验实践参加了试验结束焦点小组，共计12个焦点小组。结果：5个主题出现：（1）参与研究使参与者对CKD登记更加积极;（2）临床医生并不总是向患者解释他们患有CKD;（3）虽然从业者改善了对CKD的监测，但许多人怀疑它改善了护理，并且更受按业绩付费措施的激励;（4）研究干预措施对实践的影响总体上是积极的，特别是与专家的互动，包括在ABE;（5）研究激发了未来临床实践的想法。缺乏对临床指南的认识和对其有效性的怀疑是改变的障碍。虽然按业绩计薪激励措施是变革的主要驱动力，但提高质量的干预措施可以发挥补充作用。
Objectives: This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place.Setting: 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial).Participants: The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend.Interventions: Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach.Results: 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice.Conclusions: Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence.