Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation

Abstract

Background There are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice. Quality-improvement (QI) initiatives aim to reduce these gaps. This study evaluated a QI program (QPulse) that focussed on CVD assessment and management. Methods This mixed-methods study explored the implementation of guidelines and adoption of a QI program with a CVD risk-reduction intervention in 34 general practices. CVD screening and management were measured pre- and post-intervention. Qualitative analyses examined participants’ Plan-Do-Study-Act (PDSA) goals and in-depth interviews with practice stakeholders focussed on barriers and enablers to the program and were analysed thematically using Normalisation Process Theory (NPT). Results Pre- and post-intervention data were available from 15 practices (n = 19,562 and n = 20,249, respectively) and in-depth interviews from seven practices. At baseline, 45.0% of patients had their BMI measured and 15.6% had their waist circumference recorded in the past 2 years and blood pressure, lipids and smoking status were measured in 72.5, 61.5 and 65.3% of patients, respectively. Most high-risk patients (57.5%) were not prescribed risk-reducing medications. After the intervention there were no changes in the documentation and prevalence of risk factors, attainment of BP and lipid targets or prescription of CVD risk-reducing medications. However, there was variation in performance across practices with some showing isolated improvements, such as recording waist circumference (0.7-32.2% pre-intervention to 18.5-69.8% post-intervention), BMI and smoking assessment. Challenges to the program included: lack of time, need for technical support, a perceived lack of value for quality improvement work, difficulty disseminating knowledge across the practice team, tensions between the team and clinical staff and a part-time workforce. Conclusion The barriers associated with this QI program was considerable in Australian GP practices. Findings highlighted they were not able to effectively operationalise the intervention due to numerous factors, ranging from lack of internal capacity and leadership to competing demands and insufficient external support. Trial registration Australian New Zealand Clinical Trials Reference Number (ACTRN12615000108516), registered 06/02/2015.

In a large primary care data set, the CHA2DS2-VASc score leads to an almost universal recommendation for anticoagulation treatment in those aged ≥65 years with atrial fibrillation

“…Analyses were conducted on a large Australian general practice dataset collated during previous cardiovascular quality improvement and AF screening studies (2011-2019). [9][10][11][12][13] Each of these studies had ethics approval. The dataset comprised deidentified data extracted from the clinical records system at a single baseline timepoint for 'active' adult patients from 164 practices.…”

Learning from the implementation of a quality improvement intervention in Australian general practice: a qualitative analysis of participants views of a CVD preventive care project

“…The overall objective of the QPulse project was to enhance the implementation of CVD risk management guidelines in general practices. The project faced significant implementation challenges, and quantitative analysis of the quality improvement outcomes failed to demonstrate any changes in risk factor documentation, risk factor prevalence, attainment of physiological targets or prescribing for risk reduction after the intervention [23,24]. However, a detailed sub-analysis of the data did demonstrate significant variation between practices.…”

“…This paper presents a qualitative analysis of interviews with participants of a QIC project, QPulse, focused on enhancing the implementation of the Australian National Vascular Disease Prevention Alliance Guidelines 1 to manage absolute cardiovascular disease risk [23]. QPulse was a collaboration between the Central and Eastern Sydney Primary Health Network (the "PHN"), The George Institute for Global Health and Improvement Foundation Australia, funded through a Health Research Award from Bupa Health Foundation.…”

“…However, a detailed sub-analysis of the data did demonstrate significant variation between practices. Some high performing practices showed selected areas of improvement in patient data collection, such as recording weight and height [23]. Gaining a knowledge about individual general practice enablers and barriers is key to developing improved QI strategies for Australian general practices.…”

“…The current qualitative study was conducted following the completion of the QIC component of the QPulse project. Detailed information about QPulse QIC recruitment, interviewees and data collection have been reported elsewhere [23,24].…”