Abstract

Background: Supported self-management improves asthma outcomes but implementation in routine clinical practice is poor. The IMP2ART cluster randomised trial (IMPlementing IMProved Asthma self-management as RouTine) tests a theoretically-informed strategy to improve implementation in UK primary care of supported self-management and asthma outcomes (the intervention, 73 practices randomised) compared to usual care (71 practices). The strategy includes 1) expert nurse facilitation, 2) professional education for general practice staff, 3) organisational strategies (audit reports from electronic health records and an asthma review template), 4) patient resources to support self-management (patient website, review invitation letters and waiting room posters).

Aim: A process evaluation nested in the IMP2ART trial was undertaken to understand how the strategy was delivered and if/how it was adopted by practices.

Methods: We analysed quantitative data over the two-year trial period on delivery of, and response to, the IMP2ART strategy in general practices in England and Scotland randomised to the trial intervention arm. Qualitative data from practice staff interviews (n=34) and online surveys (n=46) were analysed to understand experiences.

Results: Facilitator workshops were delivered to 65 practices, with 87% of practices reporting the workshop to be helpful, and 83% reporting finding ongoing facilitator support helpful. Engagement with the education modules was good: 83% of practices completed the team module, and at least one member of staff completed the individual module in 52% of practices. An asthma review template was the least used resource, with 78% of practices reporting that they had not used it, preferring their current templates. Monthly audit and feedback reports were delivered as intended to 74% of practices, however some practices experienced report delays. Discrepancies with practices’ own audit data sometimes highlighted issues with clinical coding, however 89% of practices found reports helpful. Staff described increased confidence when audit data showed improvements or good performance, however, some felt that softer markers of success were not always captured.

Conclusion:
Whilst delivery of the IMP2ART strategy was largely successful, the process evaluation provides insights into the variability of delivery and response to the implementation of the IMP2ART strategy.