Drivers for change in primary care of diabetes following a protected learning time educational event: interview study of practitioners

Background A number of protected learning time schemes have been set up in primary care across the United Kingdom but there has been little published evidence of their impact on processes of care. We undertook a qualitative study to investigate the perceptions of practitioners involved in a specific educational intervention in diabetes as part of a protected learning time scheme for primary health care teams, relating to changing processes of diabetes care in general practice. Methods We undertook semistructured interviews of key informants from a sample of practices stratified according to the extent they had changed behaviour in prescribing of ramipril and diabetes care more generally, following a specific educational intervention in Lincolnshire, United Kingdom. Interviews sought information on facilitators and barriers to change in organisational behaviour for the care of diabetes. Results An interprofessional protected learning time scheme event was perceived by some but not all participants as bringing about changes in processes for diabetes care. Participants cited examples of change introduced partly as a result of the educational session. This included using ACE inhibitors as first line for patients with diabetes who developed hypertension, increased use of aspirin, switching patients to glitazones, and conversion to insulin either directly or by referral to secondary care. Other reported factors for change, unrelated to the educational intervention, included financially driven performance targets, research evidence and national guidance. Facilitators for change linked to the educational session were peer support and teamworking supported by audit and comparative feedback. Conclusion This study has shown how a protected learning time scheme, using interprofessional learning, local opinion leaders and early implementers as change agents may have influenced changes in systems of diabetes care in selected practices but also how other confounding factors played an important part in changes that occurred in practice.


Background
A number of protected learning time (PLT) schemes in primary care have been set up across the United Kingdom. Published evaluations have focused on organisational aspects and the views of participants of the benefits, problems and possible effects of such schemes [1][2][3][4][5][6]. There has been little published evidence of their impact on processes of care or improved patient outcomes. Reported effects on prescribing behaviour or process changes have not adequately accounted for secular (underlying) trends in performance.
It has been argued that studies of educational interventions should evaluate change in a geographical area (rather than a single practice) targeting an identifiable learning need which if addressed could lead to real improvements in patient outcomes [7]. In the case of interprofessional learning, "when [members or students of] two or more professions learn with, from and about one another to improve collaboration and the quality of care [8]" it should also be focused on a relevant problem appropriate for the multiprofessional group [4]. In order to do this a mixed methods study was conducted into the effect on practice prescribing and behaviour of an educational session on diabetes care provided by Lincolnshire TARGET (Time for Audit, Review, Guidelines, Education and Training), set up as an multidisciplinary protected learning time (PLT) scheme, and innovative in that it involved all general practices with their associated primary care teams in a large rural county of the East Midlands, United Kingdom.
The educational session was centred around the HOPE study which provided evidence that patients with coexisting diabetes and hypertension or other cardiovascular risk factors should be treated with an ACE inhibitor at a therapeutic dose (specifically ramipril 10 mg) [9] to reduce cardiovascular morbidity and mortality. An interrupted time series analysis showed a significant increase in ACE inhibitor prescribing across the county, taking into account secular change, following the educational intervention (odds ratio 1.50, 95% CI 1.07-1.93) with an increase in prescribing of ramipril by 52,345 items (31,132 items at 10 mg) at a cost of £292 k to £460 k depending on formulation [10].
The aim of this parallel qualitative study was to investigate the perceptions of practitioners on the effect of the educational event relating to their processes of diabetes care. We were interested in what practices did, if anything, to implement and sustain change as a result of the educational intervention, what the barriers to change were, what other external factors may have led to change, and which elements of the educational intervention were helpful or not helpful.

Lincolnshire TARGET
Lincolnshire TARGET was set up in 2000 with the aim of providing needs based learning for general practitioners, community nurses and administrative staff working in primary care during working hours. This was achieved by using local out-of-hours cooperatives and other internal arrangements in group practices to provide primary care services during educational sessions. Each session was organised and delivered by a team of educators, led by a clinical director with administrative support, and focused on a topic based on both local practitioner need and national priorities. The sessions involved a combination of lectures delivered by local, regional or national opinion leaders and facilitated small interdisciplinary group work involving medical, nursing and administrative staff. At the end of each session individual primary care teams worked in small groups to discuss how they might implement change as a result of the education. TARGET included educational sponsorship from a number of pharmaceutical companies and promotional stands were also a feature of the sessions. Lunch was provided before the educational meeting began but no other incentives were offered to encourage attendance.

Intervention of interest
The educational session on diabetes was delivered in November 2001 and lasted about 2.5 hours. It consisted of a welcome session outlining the objectives for the afternoon, an opening talk to set the scene of diabetes in general practice followed by parallel talks for clinicians and administrative staff. The first session for clinicians was designed to look at diabetes prevalence and screening following which a local general practitioner who had successfully implemented the findings from HOPE into his own practice was able to describe practical steps leading to improvements in ACE inhibitor prescribing for diabetes within his practice.
For other (including nonclinical) staff a talk was given from the patient's perspective by a speaker from Diabetes UK, a talk on the diabetic clinic was given by a local specialist diabetic nurse and a practical session looking at computer data, risk assessment and routine procedures, for example in reception, was given. Finally practices teams met together as a group, to discuss the barriers to improving practice processes for diabetes care, including implementation of HOPE, and considered an action plan of how they might overcome barriers and implement better systems of care. Each plan was fed back to the whole audience.

Selection and interviews
Interviewees were chosen purposively from selected practices. Nurses and general practitioners providing diabetes care in practices were specifically chosen because they were more likely to have in-depth knowledge of changes in processes of care whether related to the intervention or not. Practices were selected according to the extent of change in prescribing following the educational intervention. Stratified sampling was used to get a variety of perspectives because the quantitative study showed that there were differences in change in prescribing rates in practices in temporal relation to the intervention. Practices were therefore divided into four strata depending on change in prescribing as follows [10]: Stratum 1 (S1): little increase in prescribing before or after the educational intervention Stratum 2 (S2): some increase in prescribing before and after Stratum 3 (S3): little change before but a great deal after Stratum 4 (S4): a great deal of change before and after One of the authors (KS) selected three practices, ordered at random, from each of the four strata and invited them to take part in the qualitative interview study. If a practice declined to take part the next practice on the list from that stratum was invited. A total of twelve interviews were carried out, three from each of the four strata. Interviewees (practices) and interviewers were blinded to the practice stratum so that neither the practice, nor the interviewers were aware of the stratum from which the practice was drawn at the time of the interview (see Table 1). The audiotape from one practice in stratum 2 was inadvertently damaged precluding analysis. Informed consent was sought from participants.

Interviews and data analysis
The interviews looked for perceptions of change in diabetes care and facilitators of change. This included not only the educational session but also any other factors that may have prompted change, barriers to change and evidence of practice interventions to implement change ( Table 2). One-to-one in depth interviews took place at the practice premises in 2003, within 18 months of the educational session. They were 45 to 90 minutes in duration and conducted individually by two researchers. They were tape recorded and transcribed in full. Qualitative data from the transcripts were analysed using specific software (QSR N6). A sample of the transcripts was independently examined by all members of the project team and categories derived by induction. Categories were decided and grouped into themes through discussion. Themes were identified in the context of the stratum and the professional discipline of the interviewee and agreed through examination of transcripts by all members of the team.
Thematic analysis was used to make sense of the data. This involved examining the transcribed interviews to identify key issues and then coding and categorising text expressing these recurrent issues to form explanatory themes.

Ethics committee
Lincolnshire Research Ethics Committee (study number: 02/1/680). The study was approved for research management and governance by West Lincolnshire PCT.

Results
101 practices, 38 from East Lincolnshire, 25 from Lincolnshire South, and 38 from West Lincolnshire were included in the study. Of these, 15 were training practices, 56 Personal Medical Services (PMS), 18 single-handed practices and 59 dispensing. At least one GP attended the intervention session from 68 practices, and from 64 at least one practice nurse or health visitor attended. No clinical pro- At least one PN/HV attending 28 20 8 8 fessional attended from 25 of the practices. From 12 practices only one or more GPs attended and no nurses, from 8 practices one or more practice nurses or health visitors but no GPs, and from 56 at least one GP and at least one practice nurse or health visitor attended. All 101 practices had their prescribing data analysed for ACE inhibitor prescribing before and after the educational session and the quantitative analysis has been described in detail in a separate paper [10].
The results have been written under the five main themes emerging from the data which include changes in proc-esses of care, facilitators for change, barriers to change, sustaining change and perceived effect of PLT (See Table  3). In order to differentiate between the different strata and also the professional group of the interviewee, each quote was identified as such, for example stratum one, GP quote (S1 GP), or stratum three nurse (S3 NS). The effect of stratum on change was also explored.

Changes in processes of care
The main changes stated by interviewees in the care of patients with diabetes in the year following the educational intervention included increased used of protocols and policies; using ACE inhibitors as a first line for patients with diabetes who developed hypertension; switching patients to glitazones; increased use of aspirin and statins; putting patients on insulin either directly or by referral to secondary care; quicker titration of drugs leading to increased prescriptions; increased screening and review of patients with diabetes. Practices in strata 1 and 2, though still aspiring to improve care were less able to specify the precise interventions by which they did this. Increased review leading to additional prescribing "We're seeing diabetic patients much more regularly than we did, and we're noticing changes in their blood pressure and cholesterol levels, making sure they have more screenings and all their checks are in place." (S1 GP)

Information sources
Information was received from a number of sources including the Primary Care Organisations and professional journals but drug representatives were also seen as an important source of information. "I think they [drug representatives] probably played a bit more of a part here that they usually let them do which is that they did persuade me that glitazones were probably a good thing..." (S4 GP)

Clinical audit
Audit and benchmarking care against other practices' performance was perceived to be an important driver for change in all practices interviewed. Clinicians in most practices used 'real-time' entry to improve data recording but for some practices this was a relatively recent phenomenon.

"...We've taken a sample of about 50-60 patients we've picked up at random and we've followed them right the way through and it's a report back but a lot of things have changed over those two years so its quite interesting." (S3 NS)
"You're in line with your colleagues and thinking along the same line I think sort of group approach... everybody's calling the same tune, at least within this county." (S1 GP)

Role redesign
A number of practices encouraged nurses, particularly the diabetes nurse, to take a leading role in delivery. Health care assistants also supported diabetes care, either working alongside the nurse or to protocols supervised by the general practitioner (GP). GPs appreciated that using health care assistants in this way was a radical change.

Patient involvement and empowerment
Clinicians interviewed expressed ambivalence about patient empowerment. Some clinicians felt that patients were increasingly knowledgeable about their condition, often using the Internet for information, and this affected how they provided services.
Giving patients written information about their condition was seen as empowering. Some practices offered routine annual reviews whilst others actively encouraged patients to decide when to contact the practice for additional care or advice. Patient held records were also mentioned by one practice that felt that they helped inform patients about what had been done for them.

Risks versus benefits of medication
One GP felt concern about putting patients who appeared otherwise healthy onto an increasing number of potentially harmful medications in order to meet targets.

Perceived effect of TARGET on diabetes care
Participants expressed that the research outcomes of major studies and government policy had a big impact on practices. What difference did the protected learning time session for diabetes make? Only one practice interviewed stated that they had not attended TARGET. This GP was a single-handed practitioner in stratum 1 and gave 'lack of time' as his reason for non-attendance. Practices were mixed in their opinions about whether TARGET had made a difference in their care provision for patients with diabetes. Although many felt that they were already implementing change the majority of practices cited new systems such as screening at-risk patients, providing information for receptionists, organising foot care and putting patients on aspirin as resulting directly from TARGET.
Group work was specifically mentioned as helpful by two practices where working with 'fellow GPs', colleagues from different disciplines and other practices was seen as beneficial. Peer pressure and being seen to be 'in line' with colleagues appeared to be another important factor. Inhouse training using protected time was mentioned by two practices in strata 3 and 4 as a way of developing their individual practice's systems. Expert speakers (non GP) had a limited appeal to some practitioners whereas other general practitioners were welcomed.

Effect of stratum on change
Practices in strata 1 and 2 (little or some change before and after the educational intervention) generally reported making opportunistic rather than systematic improvements whereas strata 3 and 4 practices (a great deal of change before or after the educational intervention) tended to cite influencing factors and resulting changes in practice more often. Changes in processes were report to occur in every practice to some extent, but for participants from strata 3 and 4 described change at a faster pace. Practices in stratum 4 in particular tended to have been early adopters, one practice in this group stating that they started implementing 'HOPE' very soon after publication. Practices in strata 3 & 4 were more likely to mention utilising protected learning time for in-house training in order to develop the practices' systems and teamworking. Practices in strata 3 & 4 were also more likely to acknowledge the benefit of diabetes education whereas those practices in stratum 1 reported themselves to be under too much pressure from other areas of work to undergo additional education.

Principal findings
Despite some interviewees reporting that protected learning time (PLT) had not been a major influence in bringing about change in prescribing, others indicated that PLT was one of a number of key drivers for bringing about change in diabetes care in their practice [11]. Changes occurring after the educational intervention included using ACE inhibitors as a first line for patients with diabetes who developed hypertension, increased use of aspirin, switching patients to glitazones and commencing insulin; such changes by leading to better control of glucose and cardiovascular risk factors are known to reduce complications of diabetes.
Reported facilitators of change were financially driven performance targets, research evidence and national guidance. Despite many interviewees suggesting that they had already looked at diabetes care provision and that the educational session may not necessarily have influenced this, most practices offered explicit examples of change introduced directly as a result of the session. Other factors for change linked to the educational session were peer support, teamworking and benchmarking through audit and comparative feedback.

Strengths and weaknesses
The main strengths of the study were that it provided an explanatory framework for changes linked to a quantitative study into the effect of protected learning time on prescribing, that the practices were stratified for inclusion according to change in prescribing and that prescribing status was blinded by both interviewee and interviewer.
Limitations included the small number of practices from each stratum and the potential for recall bias. Respondent validation, or other data validation, was not undertaken.

Context of other literature
The findings support the role of peer influence and modelling in the learning process [12] which was more than simply from networking opportunities [2]. The protected learning session provided influential sources of information and delivered a personalised message, based on individual experience focusing on specific evidence linked to clear outcomes and encouraging change [13]. Local opinion leaders and early adopters who contributed to the educational programme may have had a beneficial effect on adoption by others [14] and the interactive nature of the educational process was more likely to improve outcomes compared to didactic lectures [15], a view supported by adult educational theory [16]. Respondents highlighted audit and benchmarking as facilitators for change and although evidence for this from the literature is equivocal [17] it could be argued that the audit process was a mechanism for peer influence as well as providing a basis for measurement of change. Interprofessional learning may also have had a positive impact [8] given that members of practices teams had the opportunity to discuss potential changes during the session. This approach was similar in some respects to the academic detailing approach for practice teams [18].

Conclusion
This study has shown how a protected learning time scheme, using local opinion leaders and early implementers as change agents and audit and feedback, was one of a number of factors supporting changing systems of diabetes care in some practices. Utilising a combination of approaches to address barriers to change [19] was integral to the concept of the protected learning time scheme. The educational session addressed barriers to change, known to be helpful in modifying outcomes, by sharing learning across practices [20]. Various other evidence based strategies to improve performance, such as identifying with the concerns of practitioners and patients, using practicebased active learning methods, delivery by opinion leaders and peers, encouraging collaboration and teamwork were employed as part of the teaching programme [21].