Initial process evaluation findings from the At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK (ARRISA-UK) trial: practice characteristics, engagement and early experiences of the intervention

Problem

Most deaths and hospitalisations due to asthma are preventable. The ARRISA-UK trial is investigating whether, compared to usual care, a GP practice-level intervention decreases the proportion of ‘at-risk’ asthma patients who experience asthma-related A&E attendances, hospitalisations or death over 12 months. This presentation reports initial findings from a nested process evaluation, describing characteristics of recruited practices, and their engagement with and early experiences of the intervention.

Approach

The ARRISA-UK study is a UK-wide cluster-randomised controlled trial of an intervention that involves identification and flagging of at-risk asthma patients’ electronic records and web-based training of practice staff to support implementation of practice-wide actions in response to the flags. A mixed-methods process evaluation is exploring implementation, mechanisms of action and the influence of contextual factors (e.g. practice characteristics) on the intervention. Quantitative and qualitative data from study baseline and post-training questionnaires, training software, practice-specific action plans and initial focus groups and interviews with staff were analysed to describe practice characteristics, and engagement with, and initial implementation and staff experiences of, the ARRISA-UK approach.

Findings

The 275 recruited practices, from across 14 English Clinical Research Network Regions, 7 Welsh and 5 Scottish Health Boards, had a median list size of 8801 (range 1667-37800) and identified a median of 33 (range 1-197) at-risk asthma patients per practice and over 10,000 in total. There was considerable variation in other practice characteristics (e.g. software system, level of asthma special interest, area deprivation). Despite some early documented difficulties with technology and staff turnover, at least 409 staff (GPs, nurses, receptionists/administrators, dispensers/pharmacists) from 133 (96%) of 139 intervention practices completed a substantial proportion of the individual on-line training, reflecting a median of 3 (maximum of 9) staff at practices with any trainees. 128 (92%) practices also completed group training to prepare Action Plans, attended a webinar and activated flagging. Action plans disseminated to staff to outline actions to take in response to the flags varied in content and detail but illustrated ways to enhance access to, and uptake of, asthma-related services by at-risk patients, including implementation of protocols for reception, capitalising on opportunistic encounters and communicating with out-of-hours where possible. Further analyses of data from the training software, post-training questionnaires and early focus groups/interviews with practice staff are underway.

Consequences

The ARRISA-UK intervention represents a pragmatic, practice-wide approach to targeting at-risk asthma patients which has been implemented across a range of GP practices. Early data suggest that the intervention has generally engaged all practice staff groups, particularly receptionists, and been well-received. Initial findings are informing ongoing data collection via a Practice Experience Questionnaire, and focus groups and interviews with purposively sampled practices, staff and patients to further explore variations in implementation and potential reasons for its success, or otherwise.