Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed-methods process evaluation

Cindy Mann (Lead / Corresponding author), Ali R. G. Shaw, Bruce Guthrie, Lesley Wye, Mei-See Man, Katherine Chaplin, Chris Salisbury

    Research output: Contribution to journalArticle

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    Abstract

    Objectives: During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions.

    Design: Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients.

    Setting: Thirty-three UK general practices in three areas.

    Participants: The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview.

    Results: Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns.

    Conclusions: Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention.

    Trial Registration Number: ISRCTN06180958.

    Original languageEnglish
    Article numbere031438
    Pages (from-to)1-12
    Number of pages12
    JournalBMJ Open
    Volume9
    Issue number11
    DOIs
    Publication statusPublished - 6 Nov 2019

    Fingerprint

    General Practice
    Comorbidity
    Interviews
    Patient Care Planning
    Nurse Administrators
    Patient-Centered Care
    Continuity of Patient Care
    Ticks
    Focus Groups
    Administrative Personnel
    General Practitioners
    Maintenance
    Quality of Life
    Health

    Keywords

    • Implementation failure
    • Implementation fidelity
    • Intervention failure
    • Multimorbidity
    • Null trial
    • Patient-centred
    • Primary care
    • process evaluation

    Cite this

    Mann, Cindy ; Shaw, Ali R. G. ; Guthrie, Bruce ; Wye, Lesley ; Man, Mei-See ; Chaplin, Katherine ; Salisbury, Chris. / Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice : mixed-methods process evaluation. In: BMJ Open. 2019 ; Vol. 9, No. 11. pp. 1-12.
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    abstract = "Objectives: During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions.Design: Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients.Setting: Thirty-three UK general practices in three areas.Participants: The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview.Results: Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49{\%} of patients receiving both intended reviews, 30{\%} partially reviewed). In completed reviews >90{\%} of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns.Conclusions: Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention.Trial Registration Number: ISRCTN06180958.",
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    Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice : mixed-methods process evaluation. / Mann, Cindy (Lead / Corresponding author); Shaw, Ali R. G.; Guthrie, Bruce; Wye, Lesley; Man, Mei-See; Chaplin, Katherine; Salisbury, Chris.

    In: BMJ Open, Vol. 9, No. 11, e031438, 06.11.2019, p. 1-12.

    Research output: Contribution to journalArticle

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    T1 - Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice

    T2 - mixed-methods process evaluation

    AU - Mann, Cindy

    AU - Shaw, Ali R. G.

    AU - Guthrie, Bruce

    AU - Wye, Lesley

    AU - Man, Mei-See

    AU - Chaplin, Katherine

    AU - Salisbury, Chris

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    KW - Patient-centred

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