The At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK (ARRISA-UK) trial: How has the ARRISA-UK intervention been experienced and acted upon by different types of GP practices? A longitudinal, comparative case study

Problem

Most deaths and hospitalisations due to asthma are preventable. The ARRISA-UK study is a cluster-randomised control trial across 275 GP practices evaluating whether a complex, practice-level intervention reduces the proportion of ‘at-risk’ asthma patients experiencing asthma-related A&E attendances, hospitalisations or death over 12 months, compared to usual care. The student-led study reported here is being conducted as part of a nested process evaluation of the ARRISA-UK intervention. It aims to describe in depth how the intervention was experienced and acted upon in different practices, and explore how contextual factors (e.g. practice characteristics) influenced this.

Approach

Intervention practices were supported in identifying and adding flags to at-risk asthma patients’ records. Staff representatives (including receptionists, nurses, GPs and pharmacists) participated in online training which culminated in generation of practice-specific action plans for management of at-risk asthma patients that practices were left to implement. For a purposively selected subsample of 4-6 practices that differ in terms of key practice characteristics, quantitative (e.g. training records, Likert-type questionnaire responses) and qualitative data (e.g. action plans, free-text questionnaire responses, focus groups) collected for the process evaluation are being analysed and integrated to (1) describe in depth how these practices engaged with the ARRISA-UK intervention, up to and including writing an action plan, (2) describe practices’ implementation of the action plan, and (3) explore any linkages between engagement, implementation and practice characteristics (e.g. practice size, area deprivation). A longitudinal comparative case study approach will generate a detailed picture of different practice experiences and make comparisons between them.

Findings

Initial findings from the 128 intervention practices which activated flags for at-risk asthma patients (92% of total) indicate wide variations in practice characteristics (e.g. list size 1667-32,868 patients, 1-121 at-risk asthma patients identified), the type and number of staff completing training (median 3, range 1-9) and content of action plans (median 22, range 5-38 action points per practice, most representing agreed actions for receptionists and clinicians in response to flags). The impact of these differences on experiences of the intervention and implementation of action plans were apparent in focus groups with 17 practices. Further analyses and integration of quantitative and qualitative findings from up to 6 of these practices are underway. These case studies will be presented to provide detailed illustrations of differing patterns of engagement with the intervention and implementation of action plans, and how contextual factors have influenced these.

Consequences

Identified differences in how different GP practices respond to and act upon the ARRISA-UK intervention could impact on its effectiveness. These findings could therefore highlight potential mediators and moderators of patient care and outcomes for exploration when full follow up data are available and indicate ways to improve any future implementation of the ARRISA-UK intervention in different types of practice.