Tina Drud Due

The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial

BackgroundThe Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention.MethodThe study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups.ResultsWe randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program.ConclusionThe mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care.Trial registrationClinicalTrials.gov: NCT01297075

Role enactment of facilitation in primary care: a qualitative study

BackgroundFacilitation is a widely used implementation method in quality improvement. Reviews reveal a variety of understandings of facilitation and facilitator roles. Research suggests that facilitation interventions should be flexible and tailored to the needs and circumstances of the receiving organisations. The complexity of the facilitation field and diversity of potential facilitator roles fosters a need to investigate in detail how facilitation is enacted. Hence, the purpose of this study was to explore the enactment of external peer facilitation in general practice in order to create a stronger basis for discussing and refining facilitation as an implementation method.MethodsThe facilitation intervention under study was conducted in general practice in the Capital Region of Denmark in order to support an overall strategy for implementing chronic disease management programmes. We observed 30 facilitation visits in 13 practice settings and had interviews and focus groups with facilitators. We applied an explorative approach in data collection and analysis, and conducted an inductive thematic analysis.ResultsThe facilitators mainly enacted four facilitator roles: teacher, super user, peer and process manager. Thus, apart from trying to keep the process structured and focused the facilitators were engaged in didactic presentations and hands-on learning as they tried to pass on factual information and experienced based knowledge as well as their own enthusiasm towards implementing practice changes. While occasional challenges were observed with enacting these roles, more importantly we found that a coaching based role which was also envisioned in the intervention design was only sparsely enacted meaning that the facilitators did not enable substantial internal group discussions during their facilitation visits.ConclusionFacilitation is a complex phenomenon both conceptually and in practice. This study complements existing research by showing how facilitation can be enacted in various ways and by suggesting that some facilitator roles are more likely to be enacted than others, depending on the context and intervention design and the professional background of the facilitators. This complexity requires caution when comparing and evaluating facilitation studies and highlights a need for precision and clarity about goals, roles, and competences when designing, conducting, and reporting facilitation interventions.

How well do general practitioners know their elderly patients' social relations and feelings of loneliness?

BackgroundSocial relationships are important to people and affect their quality of life, morbidity and mortality. The aim of this study was to examine the correlation between elderly patients’ descriptions of their social relations and feelings of loneliness, and their general practitioners’ assessments of these.MethodsCross-sectional study in 12 general practices in the Capital Region of Denmark. During a three-week period each practice asked their patients aged 65 and older to fill out a questionnaire regarding health, social relations and loneliness; the general practitioner (GP) filled out a matching questionnaire regarding their perception of the patient’s social relations and loneliness. Data were collected from February to September 2014.ResultsOf the 767 eligible patients 476 were included in the study. For 447 patients both GP and patient had answered at least one question on loneliness or social participation. The correlations between patients’ and GPs’ answers regarding social participation and loneliness were low (0.04–0.26). While GPs were less able to identify lonely patients and patients with low social participation, they were better at identifying not-lonely patients or those with high social participation. It was especially difficult for GPs to identify lonely patients when they were not living alone or if the GP believed the patient had high social participation.ConclusionGPs have difficulty identifying patients who are lonely or have low social participation and this ability is further diminished when the patients do not live alone or if the GP believes them to have high social participation. Given the consequences of loneliness and limited social participation on patients’ health and well-being, and GPs’ limited ability to identify these patients, GPs’ obligations and resources in this area need to be clarified.

Influences of peer facilitation in general practice – a qualitative study

BackgroundPractice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings.We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation.MethodsThe facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis.ResultsMost of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators’ being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation.ConclusionPractice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities.