title: Process evaluation of the data-driven quality improvement in primary care (DQIP) trial: active and less active ingredients of a multi-component complex intervention to reduce high-risk primary care prescribing.
abstract: Two to 4% of emergency hospital admissions are caused by preventable adverse drug events. The estimated costs of such avoidable admissions in England were £530 million in 2015. The data-driven quality improvement in primary care (DQIP) intervention was designed to prompt review of patients vulnerable from currently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelets and was found to be effective at reducing this prescribing. A process evaluation was conducted parallel to the trial, and this paper reports the analysis which aimed to explore response to the intervention delivered to clusters in relation to participants' perceptions about which intervention elements were active in changing their practice.
  
  
  
  Data generation was by in-depth interview with key staff exploring participant's perceptions of the intervention components. Analysis was iterative using the framework technique and drawing on normalisation process theory.
  
  
  
  All the primary components of the intervention were perceived as active, but at different stages of implementation: financial incentives primarily supported recruitment; education motivated the GPs to initiate implementation; the informatics tool facilitated sustained implementation. Participants perceived the primary components as interdependent. Intervention subcomponents also varied in whether and when they were active. For example, run charts providing feedback of change in prescribing over time were ignored in the informatics tool, but were motivating in some practices in the regular e-mailed newsletter. The high-risk NSAID and anti-platelet prescribing targeted was accepted as important by all interviewees, and this shared understanding was a key wider context underlying intervention effectiveness.
  
  
  
  This was a novel use of process evaluation data which examined whether and how the individual intervention components were effective from the perspective of the professionals delivering changed care to patients. These findings are important for reproducibility and roll-out of the intervention.
  
  
  
  ClinicalTrials.gov, NCT01425502 .
authors.affiliation: Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK. aileen.grant@stir.ac.uk.
authors.forename: Aileen
authors.identifier: 0000-0001-6146-101X
authors.initials: A
authors.lastname: Grant
authors.affiliation: Medicines Governance Unit, NHS Tayside, Dundee, UK.|Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
authors.forename: Tobias
authors.initials: T
authors.lastname: Dreischulte
authors.affiliation: Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
authors.forename: Bruce
authors.initials: B
authors.lastname: Guthrie
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards; D016000:Cluster Analysis; D011307:Drug Prescriptions; D004739:England; D058006:General Practice / Q000191:economics / Q000193:education / Q000592:standards*; D006801:Humans; D009042:Motivation; D009524:Newspapers as Topic; D061214:Patient Safety; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D017064:Process Assessment, Health Care; D012308:Risk Management / Q000379:methods; D012606:Scotland; D019564:Unnecessary Procedures / Q000191:economics / Q000706:statistics & numerical data
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D010975:Platelet Aggregation Inhibitors
keywords: Family practice; General practice; Prescribing; Process evaluation; Quality and safety; Randomised controlled trials