title: Action to Support Practices Implement Research Evidence (ASPIRE): protocol for a cluster-randomised evaluation of adaptable implementation packages targeting 'high impact' clinical practice recommendations in general practice.
abstract: BACKGROUND
  There are recognised gaps between evidence and practice in general practice, a setting which provides particular challenges for implementation. We earlier screened clinical guideline recommendations to derive a set of 'high impact' indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. We aim to evaluate the effectiveness and cost-effectiveness of a multifaceted, adaptable intervention package to implement four targeted, high impact recommendations in general practice.
  
  
  METHODS
  The research programme Action to Support Practice Implement Research Evidence (ASPIRE) includes a pair of pragmatic cluster-randomised trials which use a balanced incomplete block design. Clusters are general practices in West Yorkshire, United Kingdom (UK), recruited using an 'opt-out' recruitment process. The intervention package adapted to each recommendation includes combinations of audit and feedback, educational outreach visits and computerised prompts with embedded behaviour change techniques selected on the basis of identified needs and barriers to change. In trial 1, practices are randomised to adapted interventions targeting either diabetes control or risky prescribing and those in trial 2 to adapted interventions targeting either blood pressure control in patients at risk of cardiovascular events or anticoagulation in atrial fibrillation. The respective primary endpoints comprise achievement of all recommended target levels of haemoglobin A1c (HbA1c), blood pressure and cholesterol in patients with type 2 diabetes, a composite indicator of risky prescribing, achievement of recommended blood pressure targets for specific patient groups and anticoagulation prescribing in patients with atrial fibrillation. We are also randomising practices to a fifth, non-intervention control group to further assess Hawthorne effects. Outcomes will be assessed using routinely collected data extracted 1 year after randomisation. Economic modelling will estimate intervention cost-effectiveness. A process evaluation involving eight non-trial practices will examine intervention delivery, mechanisms of action and unintended consequences.
  
  
  CONCLUSIONS
  ASPIRE will provide 'real-world' evidence about the effects, cost-effectiveness and delivery of adapted intervention packages targeting high impact recommendations. By implementing our adaptable intervention package across four distinct clinical topics, and using 'opt-out' recruitment, our findings will provide evidence of wider generalisability.
  
  
  BACKGROUND
  ISRCTN91989345.
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. t.a.willis@leeds.ac.uk.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Willis
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK. s.hartley@leeds.ac.uk.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Hartley
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. l.glidewell@leeds.ac.uk.
authors.forename: Liz
authors.initials: L
authors.lastname: Glidewell
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK. a.j.farrin@leeds.ac.uk.
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Farrin
authors.affiliation: School of Psychology, University of Leeds, Leeds, LS2 9LZ, UK. r.j.lawton@leeds.ac.uk.|Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK. r.j.lawton@leeds.ac.uk.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Lawton
authors.affiliation: Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK. Rosie.mceachan@bthft.nhs.uk.
authors.forename: Rosemary R C
authors.initials: RR
authors.lastname: McEachan
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. e.j.ingleson@leeds.ac.uk.
authors.forename: Emma
authors.initials: E
authors.lastname: Ingleson
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK. p.heudtlass@leeds.ac.uk.
authors.forename: Peter
authors.initials: P
authors.lastname: Heudtlass
authors.affiliation: Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK. m.collinson@leeds.ac.uk.
authors.forename: Michelle
authors.initials: M
authors.lastname: Collinson
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. s.clamp@leeds.ac.uk.
authors.forename: Susan
authors.initials: S
authors.lastname: Clamp
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. c.a.hunter@leeds.ac.uk.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Hunter
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. v.l.ward@leeds.ac.uk.
authors.forename: Vicky
authors.initials: V
authors.lastname: Ward
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. c.t.hulme@leeds.ac.uk.
authors.forename: Claire
authors.initials: C
authors.lastname: Hulme
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. d.meads@leeds.ac.uk.
authors.forename: David
authors.initials: D
authors.lastname: Meads
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. d.bregantini@leeds.ac.uk.
authors.forename: Daniele
authors.initials: D
authors.lastname: Bregantini
authors.affiliation: West Yorkshire Research Service, Bradford Districts Clinical Commissioning Group, Douglas Mill, Bradford, BD5 7JR, UK. Paul.carder@bradford.nhs.uk.
authors.forename: Paul
authors.initials: P
authors.lastname: Carder
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. r.foy@leeds.ac.uk.
authors.forename: Robbie
authors.initials: R
authors.lastname: Foy
mesh_terms: D001281:Atrial Fibrillation / Q000188:drug therapy; D015415:Biomarkers; D035843:Biomedical Research / Q000458:organization & administration*; D016000:Cluster Analysis; D003920:Diabetes Mellitus / Q000188:drug therapy; D019317:Evidence-Based Medicine; D058006:General Practice; D006801:Humans; D006973:Hypertension / Q000188:drug therapy; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D015397:Program Evaluation / Q000379:methods*; D016032:Randomized Controlled Trials as Topic
chemical_list: D015415:Biomarkers