Table 4 Intervention description based on TIDIER [25]

Rationale

Control interventions

Materials and training

Practice-specific quarterly audit reports

Each report contained a comparison of the practices’ behaviour or outcomes in relation to the other participating practices within their locality (i.e. their Clinical Commissioning Group responsible for commissioning services) and all participating practices across West Yorkshire to reflect on progress and to prompt the need for change. Information on clinical recommendations and potential change strategies were provided. Consequences of inaction were described. Practices were encouraged to set goals based on graded tasks (based on the number of clinical recommendations and number of patients to be targeted within each recommendation) and use an action planning template to detail who would do what; in what circumstances; and how and when the achievement would be reviewed. Subsequent reports included potential actions identified during outreach sessions.

Computerised searches

Searches could be included in the practice’s Clinical Information System (CIS) to systematically identify all patients whose care should be reviewed and facilitate repeat searching.

Short and longer significant event audit (SEA) templates

Short and longer forms were developed for risky prescribing and anticoagulation for AF indicators to facilitate root cause analyses and action planning from harmful events or near misses.

We commissioned for and recruited experienced Pharmacist facilitators who received 2 days training aimed to increase motivation, prompt individual and group reflection, increase confidence and intention to act. For each outreach visit, a practice-specific outreach pack was developed containing: the most recent (and all previous) audit report(s); a session outline; an action plan template that included space for noting current performance, setting a target, identifying who will do what and review date; and templates for assessing costs and benefits. We did not articulate the discrepancy or specifically request that the team did so and although it is possible that the team might do this, they might also explain the lack of achievement away in other ways and not those related to behaviours. As we can only infer that this technique was deployed we did not code for it. Training in BCT coding requires that inferences are not made.

For risky prescribing nine computerised prompts were developed to be triggered within the consultation and during repeat prescribing on the basis of a clinical code algorithm for age/diagnosis/drug and duration. When triggered a brief message notified that the patient was at risk and presented one sentence of evidence-based risk (e.g. ‘This patient has CKD. NSAID use accounts for an estimated 15% of all cases of acute renal failure and 36% of drug-induced cases’). A one-click justification was required (e.g. continue with risk, add medication, or stop medication).

Two prompts were developed for anticoagulation for AF but could not be made available within the study timelines.

Patient-directed checklists

Checklists were developed to facilitate shared decision making for managing blood pressure and diabetes outcomes but could not be made available within the study timelines so were not included in the directed content analysis.

Paper-based reminders in the form of laminated information sheets were created to convey key clinical information (blood pressure, risky prescribing and anticoagulation for AF).

Pens and post-it notes were sent to all practices with a topic specific reminder to prompt behaviour.

Supportive activities

None.

Pharmacist training included a one-day face-to-face meeting with intervention developers focussing on goal setting, action planning, clinical barriers, and persuasive communication. This was followed by a half day of independent study using a folder of supporting documentation relevant to each clinical priority. The first outreach meeting of each facilitator was observed by an experienced facilitator and feedback was given.

None.

Intervention provider

Reports, searches and templates were created by the research team.

Professional outreach education company.

Reminders were created.

Mode of delivery

Reports were sent by post and e-mail.

Practices were sent invitations to use computerised searches from a task from within their clinical information system.

An email was sent from the ASPIRE team to the practice manager and colleagues introducing SEA templates.

Face-to-face sessions were offered to practices.

Practices were sent invitations to use computerised prompts from a task within their clinical information system. An email was also sent from the ASPIRE team to the practice manager and colleagues alerting them to option to accept the prompts into their CIS.

Schedule and intensity

Quarterly feedback reports.

Practices were offered access to searches and SEA templates at the beginning of the study and reminded of their availability via quarterly feedback reports.

Practices were offered an initial 30-min session. All practice staff involved in identifying/reviewing appropriate patients were invited to attend. A key clinical contact was identified to support practice engagement. Initial visits focussed on practice achievement data (from audit reports), identifying models of good practice, addressing barriers to change and creating an action plan to facilitate and review the change. Two days of pharmacist provision was offered to support patient identification and review. An additional follow-up visit was offered to review action plan progress and supportthe practice to create more challenging or attainable plans.

Practices were offered access to prompts at the beginning of the study and reminded of their availability via quarterly feedback reports.

Practices were offered access to checklists at the beginning of the study and reminded of their availability via quarterly feedback reports.

Post-it notes and pens were sent to all practices.

Tailoring

Searches could be tailored by practices, allowing them to identify patients relevant to all or individual recommendations, or adjust target values to select specific groups of patients.

Session content could be modified to practice requirements.

Prompts could be copied and modified to practice requirements.

Modifications

Fidelity of delivery, receipt and enactment