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Publication - Dr Cindy Mann

    Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice

    mixed methods process evaluation


    Mann, C, Shaw, ARG, Guthrie, B, Wye, L, Man, M-S, Chaplin, K & Salisbury, C, 2019, ‘Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed methods process evaluation’. BMJ Open.


    Objectives, design and setting
    A process evaluation was conducted alongside a cluster-randomised trial (The 3D Study), involving 1546 participants with multimorbidity in 33 UK general practices. The trial intervention enacted recommended care for people with multimorbidity including continuity of care and comprehensive biennial patient reviews supported by a purpose-designed electronic template. The mixed-methods process evaluation aimed to inform future implementation by examining implementation variation and fidelity.

    Qualitative data (interviews, focus groups and review observations) were obtained from 19 clinicians, 7 administrators and 38 patients, analysed thematically and integrated with quantitative data about implementation fidelity collected via the electronic template from all implementation practices. Analysis was blind to trial outcomes (null for quality of life and health, positive for patient-centredness) and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients.

    Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered but review observations and interviews with patients and clinicians found variation in style of component delivery, from ‘tick-box’ to patient-centred approaches. Implementation barriers included lack of skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns.

    Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for sub-optimal implementation can inform a re-designed intervention for further evaluation and/or wider implementation.

    Trial registration number
    ISRCTN06180958 registered 18.2.2014

    Full details in the University publications repository