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Positive experiences with a specialist as facilitator in general practice

Marius Brostrøm Kousgaard & Thorkil Thorsen,

1. jun. 2012
14 min.

Faktaboks

Fakta

Educational interventions for quality improvement in general practice have been carried out for more than 20 years [1]. While effects have varied across studies and contexts, active intervention strategies have generally been more effective than strategies relying exclusively on passive information transfer [1, 2]. Hence, the employment of facilitators in various kinds of outreach visit projects has accelerated during the past decade, and this has increased the need for studies that focus on the experiences of health professionals participating in such programs [3, 4]. Also, since general practitioners (GPs) (or pharmacists) have typically been used as facilitators in such interventions [3, 5-8], there is a lack of knowledge of how other professionals function as facilitators [3]. In fact, some studies can be taken to suggest that other professionals will have problems occupying this role since they do not have sufficient legitimacy and experience from general practice [3, 4, 6].

This article focuses on a facilitator project (see Table 1) in which a medical specialist (endocrinologist) acted as a facilitator for quality improvement in general practice on the basis of standardized data on clinical quality. The issue of medical specialists acting as facilitators in general practice is important to explore for at least two reasons. Firstly, the transfer of knowledge between secondary and primary care is usually considered an important means to improve the quality of chronic care, and in many health care systems there is a growing interest in supporting collaborative arrangements between hospitals and general practice [10-12]. Secondly, educational interaction between hospital-based specialists and GPs has traditionally been sparsely researched [13], and only few studies have been published in which medical specialists attempt to facilitate learning from quality data. An exception to this is Smith et al 2008 [14], who report on a telemedicine intervention where endocrinologists provided e-mail feedback on patient data to GPs. In the present article, we present the findings from a qualitative study of the above-mentioned facilitation project which was carried out in 2010. The purpose of the article is to articulate the experiences and assessments of the GPs and nurses participating in the facilitation sessions.

MATERIAL AND METHODS

The article is based on a qualitative study employing observations and interviews. First, we observed (and audio-recorded) the seven learning sessions between the facilitator and the professionals from the nine participating clinics (Table 2). The telephone sessions were observed from the facilitator’s office. The participants had been informed beforehand that a passive observer would be present during the sessions, and the observer presented himself briefly at the beginning of each session. Second, semi-structured interviews [15] were carried out in all participating clinics 1-2 weeks after each session. GPs and nurses were interviewed separately in order to let the nurses express themselves more freely (considering the employer-employee relationship characteristic of general practice as well as the traditional professional hierarchy between nurses and doctors) in a situation where opinions might differ. Observation notes and recordings from the sessions were used to adjust the interview guide prior to each interview (adding specific questions in light of the specific contents of each session). The interview guide addressed the overall experience of the sessions, reflections on the topics covered during the sessions, the usefulness of advice given, perceived learning outcomes and an assessment of the facilitator. The interviews had a duration of 30-45 minutes. Having completed these interviews, a one-hour interview was carried out with the facilitator in order to explore her perceptions of – and reflections on – the sessions. This provided an additional perspective on the sessions serving to enhance the credibility of the study [16]. All interviews were recorded and transcribed for analysis of the central themes of the study (i.e. thematic re-ordering of interview passages and comparison of statements within and across the interviews) [17].

Trial registration: not relevant.

RESULTS

Taking departure in the indicator-based data set from general practice, the facilitator sessions primarily focused on pharmacological issues related to diabetes treatment (see Table 3). Issues of local collaboration and referral, often associated with arrangements for improving chronic care across sectors, played no prominent role in the sessions of the present study as the participating clinics did not belong to the uptake area of the hospital at which the facilitator was employed.

Overall experiences and perceived learning outcomes

Generally, the professionals described their participation in the facilitation sessions as a very positive and motivating experience. In all clinics, the respondents perceived that their time was well spent on the sessions, and they expressed an interest in participating in future sessions with a medical specialist. The GPs appreciated the opportunity to review their quality data with a specialist and to discuss difficult patient cases along with the pros and cons of specific drugs and combinations hereof (Table 4, Quotation #1 (Q1)). The nurses, who spend much of their time handling diabetes patients, were even more enthusiastic since the sessions afforded them with an occasion to take time to evaluate the procedures and the results of the clinic together with the GPs (Table 4, Q2).

For several of the professionals, it was also gratifying to have their efforts recognized by an expert in the field. While no radical changes in clinical practice resulted from the sessions, most participants could point to specific learning outcomes in the form of planned or implemented changes resulting from the sessions:

– Intensification of pharmacological treatment concerning cholesterol, blood pressure or microalbuminuria (C2, C4, C8, C9).

– Introduction of immediate prescription of anti-diabetics (metformin) when diagnosing a patient with type 2 diabetes (C6, C9).

– Introduction of glucagon-like peptide-1 (GLP-1) drugs, e.g. Victoza (C6, C7).

– Drug replacement (Insulatard for Levemir) (C6).

– Combining angiotensin-converting-enzyme (ACE) inhibitors with thiazid (C3).

– Increased attention to specific patients at particular risk (e.g. impaired renal function) (C1).

– Reduction of anti-diabetic medication for co-morbid patient on multiple medications (C3).

– Motivation of patients to measure blood sugar at home (C9).

– Nurse-led initiation of more systematic follow-up on patients based on indicator data (C8).

Apart from these specific points, most participants also reported increased motivation to review feedback data from the national indicator database. For two of the GPs (GP4, GP5), most of the knowledge relayed by the specialist was known in advance, and the learning outcome mainly consisted in making a few adjustments in the balancing of known options and concerns in relation to difficult patient cases. These two sessions were the only ones in which the facilitator experienced that she had not quite succeeded in conveying her message of intensified pharmacological treatment. In another clinic (C1), located in a relatively affluent area, the session had not given rise to much change, since the patients in this clinic were quite well-motivated, compliant and well-regulated.

During the learning sessions, very few explicit disagreements arose between the facilitator and the professionals from general practice. The interviews subsequently confirmed that the GPs and nurses had mostly agreed with the specialist concerning the goals and means of diabetes treatment (Table 4, Q3, Q4). The few differences noted by the participants were primarily attributed to the different contexts of care of the (hos- pital-based) facilitator and the participants from gen- eral practice. Particularly, in some cases, the continuity of care in general practice seemed to promote a less ‘‘aggressive’’ pharmacological approach than that generally favoured by the specialist (Table 4, Q5, Q6).

Assessments of the endocrinologist as facilitator

All participants commended the endocrinologists’ way of engaging with them and their data (see Table 3). The participants perceived that the specialist found a good balance between listening, asking questions, pointing to areas of improvement and giving specific advice. They also appreciated that the specialist had recognized the various challenges of diabetes treatment and acknowledged that it may not be possible to reach the ideal indicator targets for all patients. Although the specialist could not draw on working experience from general practice, her extensive knowledge of existing research evidence combined with years of clinical experience in an out-patient clinic helped strengthen her standing with the GPs (Table 4, Q7). None of the participants expressed that they had felt uncomfortable or threatened by the situation in which a specialist could access and comment on indicator data from their clinics (Table 4, Q8). One GP would actually prefer the endocrinologist to take a more aggressive approach since this might not only serve to challenge and inspire his own professional practice, but also the world view of the endocrinologist (Table 4, Q9). However, this GP also recognized the dangers of a more aggressive approach, especially at the first session (Table 4, Q10).

DISCUSSION

Both the GPs and nurses described the facilitation sessions as a very positive experience; and in most clinics, the professionals could point to specific learning outcomes primarily related to pharmacological questions. Compared to existing studies on outreach visits and academic detailing in general practice, the findings of this study are notable for three reasons. First, the facilitation sessions evolved around a unidirectional transfer of knowledge from the specialist to the generalists. Theoretically, this unidirectional learning approach might be viewed as problematic in an era in which the traditional hierarchical relationship between specialists and generalists is challenged as general practice asserts its own particular identity [13]. Second, some studies have shown that GPs can have doubts over the objectivity and independence of external facilitators [6]. Third, recent studies have suggested that sharing a common experience as GPs is an advantage when acting as facilitator in general practice [4], and this may call into question whether other health professionals than GPs are able to "convey the necessary tacit knowledge to general practitioners concerning medical topics" [3, p. 273]. However, the facilitation sessions and the subsequent reflections by the respondents do not suggest that the facilitator was disadvantaged by the fact that she was an external specialist. In fact, the facilitator was well-received in all clinics, and the GPs and nurses experienced that the specialist succeeded in inspiring them to reflect on their treatment regimes as well as in providing them with useful professional knowledge and advice. Also, on issues of pharmacological treatment, most respondents preferred the facilitator to be a medical specialist rather than a GP (although it should be kept in mind that the study was not designed to compare hospital-based specialists with GPs as facilitators).These findings may be ascribed to several factors:

1. During the past 5-10 years several steps have been taken to standardize and improve diabetes treatment in general practice in Denmark through the development of clinical guidelines and a national database for quality monitoring. In clinics using such tools, knowledge and attitudes may have been affected in a way which is favourable to interventions promoting new medical evidence.

2. The selection process (cf. Table 1) may have produced a group of participants who were particularly interested in diabetes and/or particularly positive to this kind of intervention. Other clinics, less interested or experienced in diabetes treatment, may have more need for a facilitator with specific knowledge of how to systematically organize diabetes treatment in a general practice.

3. The distinctive personality and pre-established skills of the specialist (as acquired through prior teaching tasks and a two-day training course in facilitation) may have produced a particularly positive learning experience.

4. The facilitator combined research-based knowledge with clinical experience. This earned her an important amount of professional credit in the learning situation and made it possible for her to discuss medical issues at the population level as well as in relation to specific patients. This interpretation is in line with previous research emphasizing the importance of pragmatically relating expert knowledge to clinical experience when communicating in a GP context [18].

In terms of the transferability of the findings in this study, the first point raises awareness to the national health care context in which the programme was carried out. Here, it may be noted that similar developments in terms of guidelines and indicators are taking place in several other countries. The second and third points relate directly to the specific design and setting of this study and suggest other possible limits of transferability. However, these points do not fundamentally disturb the basic conclusion of the study, namely that the combination of specialized knowledge and hands-on clinical experience seems to be an important advantage when using a medical specialist as facilitator in quality improvement efforts directed at pharmacological issues in general practice. Having said this, it should, of course, be noted that a high degree of acceptance and satisfaction with outreach visits does not guarantee significant improvements in clinical performance [19, 20]. Hence, further studies may evaluate the effectiveness of this kind of intervention in terms of clinical quality and costs.

Correspondence: Marius Brostrøm Kousgaard , Forskningsenheden for Almen Praksis i København og Afdeling for Almen Medicin, Institut for Folkesundhedsvidenskab, Københavns Universitet, Øster Farimagsgade 5, P.O. 2099, 1014 Copenhagen K, Denmark. E-mail: marbro@sund.ku.dk

Accepted: 20 March 2012

Conflicts of interest:None

Acknowledgement: The authors wish to thank the participating GPs and nurses as well as the following members of the steering group in charge of the facilitator project: Ulla Bjerre-Christensen, Rasmus Smith, and Thomas Drivsholm.

Referencer

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