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Table 3 OPTI-SCRIPT process evaluation: themes and supporting quotes

From: A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study)

Main theme

Sub-theme

Example quote

Delivery to practices

Academic detailing quality

“Yes, that was very informative, very straightforward, very user friendly.” (GP16, intervention practice)

Response of intervention group

Adoption as planned

“O yeah, it was very good, yeah, because actually, because they were coming in you were able to look at everything properly and they were coming in a structured review .... .just to give you a time to review the whole situation you know, in regards to all of their prescribing. It was very useful, yeah.” (GP18, intervention practice).

Adaptation

 I. Reviews without patients

“So I didn’t do it with the patients but what I did was, I think you saw from the patient records, I highlighted the notes on it, and I’d have put tags on charts when I found, yeah that needs to be done, to be addressed with their next prescription. (GP21, intervention practice).

 II. Patient information leaflet non-use

“I didn’t have to, you know, the whole process is that our patients, if they trust us, and we explain everything to them, what we are doing, em, you don’t need to, we don’t need to do that [give PILs].” (GP16, intervention practice).

Facilitators of implementation

 I. Simplicity

“It was very straightforward, it worked well I thought, em it was clear and you know, from our point of view, actually when you actually got down to it, the patient, the actual process of going through the patient was quite quick.” (GP24, intervention practice).

 II. Patient receptivity

“Absolutely no problem at all. And in fact, if anything they were quite glad, you know, that somebody is looking at their medications and making sure that it is OK, and all the rest.” (GP1, intervention practice).

Barriers of implementation

 I. Staff

“That was difficult, because, the person who manages such things is [practice nurse], who was on sick leave for most of the study. So there was nobody driving the process because [practice nurse] was away, we had only very little nursing cover in her absence, then we were doing tasks that would have been previously done by the nurse, so it was a very busy time.” (GP7, intervention practice).

Response of control group

Adaptation

“What I did was, I went in to all the files and I did a mail merge and wrote to them and changed their meds. So basically, there was a PPI - reduce the dose by half, so I just did that immediately and told them that I did that and why.” (GP3, control practice).

Recruitment and reach in individuals

Recruitment burden

“I resented the reminders … I had underestimated the amount of involvement it would require from the practice. That’s what I would say” (GP7, intervention practice)

Responses of individuals

Benefits of reviews

 I. Quality of care

“I think it is important really, because it makes people feel, well, you know that there is somebody that cares. You know, as you are getting older, that there is somebody that cares about the elderly, that they, you know, are being properly looked after and people are thinking about them.” P23.38

 II. Societal good

“I’m sure, I’m absolutely sure, there through not the patient’s fault, eh, there must be an amazing amount of pharmaceutical waste consumed by patients who don’t really eh, need it. And as you say, the purpose of your exercise is to find out if some of these can be dropped. In fact, I’m sure they could be and, the monies saved by the State could eh, be put into looking after the less fortunate people.” P1.61

 III. Necessary medication

“You’re inclined to go on things and be left on them and then you wonder should you be on them all that time, is there any side effects with them, all that kinda thing.” P7.4

Barriers to reviews

 I. GP workload

“Well, I mean, if my, if my GP has time to do that sort of thing then fine, you know.” P18.48

Future implementation

Facilitators

 I. Positive aspiration

“When you are a GP you get practices and you get bad habits, and you get good habits, and sometimes you are too busy to change your habits until it is pointed out so, anything like this is a good thing.” (GP19, control practice).

 II. Cardinal PIPs

“I think that if you keep it simple, and maybe in a structured way if you could layer it, so that you know, for 2012 we are focusing on these five issues and in 2013 we’re focusing on these, you know. There would be a little bit of slippage with last year’s issues, but over time you would introduce better prescribing.” (GP13, intervention practice).

Barriers

 I. Workload

“General practice at the moment now, as far as I can see, is getting hit by about 30 % more extra work, due to the economic downturn, so most medical card list have gone up by about 30 %, and that is increasing a huge volume of work, because those patients before, happened to be in the non-medical card area and they weren’t consulting as much. So they are now consulting, eh, much more frequently so it’s very little time left … if you had to do that every 6 months, to review all those patients. Where would you get the time?” (GP5, control practice).

 II. Reimbursement

“I often wonder if the government was to pay a fee for us to review ten patients every 3 months formally, but they’re going to say, we’re already paying you to do these prescriptions, to write these prescriptions you know, like come on guys, and they are right.” (GP13, intervention practice).