Abstract

Background and Aim: Supported self-management improves asthma outcomes but primary care implementation is poor. IMP2ART is a UK-wide programme to develop and evaluate a whole-systems strategy to help primary care practices implement supported asthma self-management. The strategy, supported for 12-months by a nurse facilitator, included facilitated formation of a practice plan, regular audit and feedback, team/professional education, and a ‘Living-with-Asthma’ website for patients and professionals. The IMP2ART randomised controlled trial included a process evaluation to explore how and why the trial achieved its outcomes.
We aimed to understand the alignment between IMP2ART implementation strategies with practice context and response.
Methods: A multi-method case study was used. Data were obtained on practice context and IMP2ART response from practice staff interviews (n=23), surveys, publicly available data, researcher and facilitator observation notes and educational module analytics. Staff interviews from other IMP2ART practices (n=13) aided interpretation. Qualitative and quantitative analyses were conducted separately by data source, then findings triangulated across data sources.
Results: The case study involved five diverse practices (England n=4, Scotland n=1) with varying population characteristics, different leadership and asthma delivery models. Audit data suggested that four out of the five practices started with delivery levels below the national average.
Practices engaged with IMP2ART in different ways with different mechanisms of change emerging. All practices embraced a commitment to staff professional development and in most practices, staff reported increased capability to support asthma self-management, albeit to varying degrees. The most sustained and proactive engagement with IMP2ART was observed in a cohesive practice with strong leadership. In this practice, there was consistent evidence that the whole team (clinical and non-clinical) were meaningfully involved in asthma care. In contrast, IMP2ART’s strategies did not reach all key staff in practices where there was less evidence of team working across professional groups. In these practices, the potential for sustained change appeared more limited.
Conclusions: Change appeared more sustainable in practices with scope to improve, strong leadership, aligned perspectives and processes across the whole practice. Facilitated implementation of asthma self-management should focus on involving the whole team and be tailored to diverse contexts.