title: A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation.
abstract: BACKGROUND
  Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals, but it is unclear how this intervention was used in practice and what factors promoted or hindered its use. This information is necessary to optimise intervention impact and maximally implement it in a post-trial context. In this study protocol, we outline our methods to conduct a theory-based, process evaluation of the intervention. Our aims are to understand how, why, and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination.
  
  
  METHODS
  We will conduct four discrete but inter-related studies taking a mixed methods approach. Our quantitative studies will examine (1) the longer term effectiveness of the intervention post-trial, (2) patient and health service level correlates with trial outcomes, and (3) the health economic impact of implementing the intervention at scale. The qualitative studies will (1) identify healthcare provider perspectives on implementation barriers and enablers and (2) use video ethnography and patient semi-structured interviews to understand how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention. We will also assess the costs of implementing the intervention in Australian primary healthcare settings which will inform scale-up considerations.
  
  
  CONCLUSIONS
  This mixed methods evaluation will provide a detailed understanding of the process of implementing a quality improvement intervention and identify the factors that might influence scalability and sustainability.
  
  
  BACKGROUND
  12611000478910.
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, NSW, 2006, Australia. bpatel@georgeinstitute.org.au.
authors.forename: Bindu
authors.initials: B
authors.lastname: Patel
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, NSW, 2006, Australia. apatel@georgeinstitute.org.au.
authors.forename: Anushka
authors.initials: A
authors.lastname: Patel
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, NSW, 2006, Australia. sjan@georgeinstitute.org.au.
authors.forename: Stephen
authors.initials: S
authors.lastname: Jan
authors.affiliation: University of Sydney, Sydney, NSW, 2006, Australia. tim.usherwood@sydney.edu.au.
authors.forename: Tim
authors.initials: T
authors.lastname: Usherwood
authors.affiliation: University of New South Wales, Sydney, NSW, 2052, Australia. m.f.harris@unsw.edu.au.
authors.forename: Mark
authors.initials: M
authors.lastname: Harris
authors.affiliation: Queensland Aboriginal and Islander Health Council, 21 Buchanan St., West End, QLD, 4101, Australia. KatiePanaretto@qaihc.com.au.
authors.forename: Katie
authors.initials: K
authors.lastname: Panaretto
authors.affiliation: University of New South Wales, Sydney, NSW, 2052, Australia. n.zwar@unsw.edu.au.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Zwar
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, NSW, 2006, Australia. jredfern@georgeinstitute.org.au.
authors.forename: Julie
authors.initials: J
authors.lastname: Redfern
authors.affiliation: University of Sydney, Sydney, NSW, 2006, Australia. jesse.jansen@sydney.edu.au.
authors.forename: Jesse
authors.initials: J
authors.lastname: Jansen
authors.affiliation: Bond University, 14 University Dr, Robina, QLD, 4226, Australia. jdoust@bond.edu.au.
authors.forename: Jenny
authors.initials: J
authors.lastname: Doust
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, NSW, 2006, Australia. dpeiris@georgeinstitute.org.au.
authors.forename: David
authors.initials: D
authors.lastname: Peiris
mesh_terms: D001291:Attitude of Health Personnel; D001315:Australia; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D016000:Cluster Analysis; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D011320:Primary Health Care / Q000592:standards*; D015397:Program Evaluation; D058996:Quality Improvement; D012308:Risk Management; D057170:Translational Research, Biomedical