Process Evaluation of a Tailored Multifaceted Approach to Changing Family Physician Practice Patterns and Improving Preventive Care

Lessons learned from the process evaluation for improving the delivery of the outreach facilitation intervention include:

Focusing on the 3 key intervention components (audit and feedback, seeking consensus on an action plan, and implementing a reminder system) and tailoring these to the needs of the practice

Preparing patient education and patient-mediated materials only if the practice requests such materials

Developing simpler strategies to encourage physicians to counsel their patients that smoke to quit smoking

Providing the facilitators an administrative assistant to reduce the amount of their time spent on administrative duties for the practices and increase time on-site

Strengths

The strengths of the study include the completeness of the data set, the theoretical framework for data collection, the use of multiple data sources and data collection methods, and the prospective data collection methodology.

Limitations

There are several limitations to the process evaluation methods. Much of the data was provided by the facilitators themselves, and therefore the possibility of bias exists. The study population consisted of HSOs, and therefore the results may not be generalizable. There is a possibility of social desirability bias in the satisfaction rates. Finally, our analyses of the process data were descriptive and exploratory.

Conclusions

Process evaluation often identifies future areas of research. Follow-up of the few practices that were dissatisfied with facilitation should be carried out to understand why they were dissatisfied. Sustainability needs to be addressed. For example, Dietrich and colleagues³⁸ found that 5-year durability of a preventive services office system depended on the physician’s preventive care philosophy. McCowan and coworkers³⁹ found that the effect of a facilitator was not sustained for 2 years. Finally, to maximize cost-effectiveness, more research is required to determine how much of a dose of facilitation is required and how frequently facilitators should visit to achieve a positive outcome.

Acknowledgments

We wish to acknowledge the financial support of the Ontario Ministry of Health, as well as the substantial contributions of the 3 nurse facilitators (Ingrid LeClaire, Ann MacLeod, and Ruth Blochlinger). We also wish to thank the many physicians and nurses who participated in the study.