Practice experiences of the At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK (ARRISA-UK) intervention: a qualitative study
The ARRISA-UK study is a cluster-randomised controlled trial evaluating an intervention intended to reduce adverse asthma outcomes, including hospital admissions or death, by improving the management of at-risk asthma patients in primary care. It comprises (i) an online training and support package for GP practice staff representatives, (ii) creation of a practice register of at-risk asthma patients and an on-screen flagging system for patients on the register, and (iii) action planning for staff dealing with these patients. 128 practices around the UK received the intervention and used the flagging system for a year. The aim of this qualitative study was to provide insights into practice experiences of the intervention and using the flagging system.
As part of the ARRISA-UK study process evaluation, focus groups and individual interviews were conducted with staff in a sub-sample of intervention practices. A sampling frame was used to ensure diversity in practice size, location, area deprivation levels, and urban/rural nature. Clinical and non-clinical staff representatives at each practice were invited to participate, and groups and interviews were conducted by researchers not involved in the creation or delivery of the intervention. Discussions were audio recorded, transcribed and analysed using a framework approach.
Over the period November 2018 to November 2019, 17 focus groups and 9 interviews were conducted with 112 staff from 18 practices in England and Scotland. Group composition varied, but across the sample there was representation of all staff roles (e.g. GPs, nurses, receptionists, pharmacists, practice managers). Most practices valued the ARRISA-UK intervention, particularly in raising staff awareness of at-risk asthma patients, and in prompting consistent application of clinical guidelines with this group. Practices differed considerably in terms of their action plans, the effectiveness of their dissemination of these plans, and in monitoring their implementation. Some focussed on changes mostly in one staff group, e.g. receptionists and the appointment systems they used; others instituted broader changes, e.g. in patient follow-up processes, prescription monitoring and addressing asthma management in all clinical consultations. Patient outcomes data were not available at the time of this analysis, but some staff thought that any adverse outcomes were more likely due to patient issues, such as poor adherence, rather than practice processes. Problems were identified by some practices with register accuracy and on-screen flagging.
The ARRISA-UK intervention appears to be feasible and acceptable to GP practice staff, and was reported to stimulate changes in management of high risk asthma patients. Attitudes to the intervention, and the apparent extent of behaviour changes by staff, varied considerably between practices. Our findings can contribute to the development of recommendations that may improve the effectiveness of the intervention and implementation of action plans.