Abstract
This thesis presents the process evaluation of implementation of a highly-complex, patient-centred intervention to improve care of patients with multi-morbidity in general practice. The intervention was evaluated in a pragmatic cluster-randomised trial. Multiple components, including continuity of care and comprehensive, longer reviews, combined to achieve a patient-centred approach. Process evaluation designs vary considerably. Common designs focus on assessing fidelity to the intervention, quantitatively and/or qualitatively. They may also investigate participants’ experience of the intervention and the impact of the trial context on implementation. This provides valuable information to interpret trial results.In this thesis, I show how I developed a comprehensive process evaluation to evaluate implementation of the complex intervention and inform interpretation of trial results, including a novel approach for evaluating implementation of patient-centredness. Because patient-centredness is defined in various ways, including the quality of patient-clinician relationships, clinician behaviours and organisational components, the process evaluation was wide-ranging. Four case studies, purposively selected to demonstrate a range of implementation success, were used for in-depth investigation of implementation, including the patient-centred approach. Context was investigated through interviews, observation and trial-wide surveys. Fidelity of intervention delivery was evaluated through observation and recordings of 28 intervention reviews and nine control reviews, and 20 post-review interviews. Finally, clinicians’ and patients’ response to the intervention were explored in 26 interviews, clinician and practice surveys and four patient focus groups. The qualitative data were analysed thematically using a combination of a priori codes based on outcomes of interest, including domains of patient-centredness, and inductive codes.
The results showed that clinicians supported a patient-centred approach, but practice circumstances and administrative systems hampered arrangement of intervention reviews. Some patients experienced reduced continuity of care during the trial for logistic reasons, but many described meaningful improvements in patient-centred domains, such as being asked about their illness experience. Patients valued the longer, comprehensive reviews to discuss all their health concerns, but some clinicians found the broad agenda challenging. Many clinicians had difficulty with the new computer template used in the intervention, but it helped ensure they delivered all components. However, template unfamiliarity could hinder communication. Some review components, for example, creating collaborative health plans and depression screening, were not always completed as intended.
In conclusion, complex, patient-centred interventions are difficult to implement and evaluate because of the multi-faceted nature of patient-centredness. Defining components and indicators of patient-centredness and evaluating from multiple perspectives led to credible findings regarding the implementation of the patient-centred approach. The findings indicated some aspects of the intervention were not always implemented as intended, for example, collaborative goal setting, but that overall patient-centredness increased, supported by template questions. Further research could usefully identify effective ways of implementing and evaluating specific patient-centred skills that would further enhance the patient-centred approach.
| Date of Award | 23 Jan 2019 |
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| Original language | English |
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| Supervisor | Chris Salisbury (Supervisor), Helen A Cramer (Supervisor) & Lesley Wye (Supervisor) |