Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation
Abstract Background Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the...
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| Format: | Article |
| Language: | English |
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BMC
2022-03-01
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| Series: | BMC Health Services Research |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12913-022-07750-8 |
| _version_ | 1819177071567437824 |
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| author | Janice Gullick John Wu Derek Chew Chris Gale Andrew T. Yan Shaun G. Goodman Donna Waters Karice Hyun David Brieger |
| author_facet | Janice Gullick John Wu Derek Chew Chris Gale Andrew T. Yan Shaun G. Goodman Donna Waters Karice Hyun David Brieger |
| author_sort | Janice Gullick |
| collection | DOAJ |
| description | Abstract Background Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings. Methods Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model. Results Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors. Conclusions Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally. |
| first_indexed | 2024-12-22T21:20:50Z |
| format | Article |
| id | doaj.art-e9717b63365a455cba40141760cf6ac9 |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-12-22T21:20:50Z |
| publishDate | 2022-03-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-e9717b63365a455cba40141760cf6ac92022-12-21T18:12:13ZengBMCBMC Health Services Research1472-69632022-03-0122111310.1186/s12913-022-07750-8Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluationJanice Gullick0John Wu1Derek Chew2Chris Gale3Andrew T. Yan4Shaun G. Goodman5Donna Waters6Karice Hyun7David Brieger8Susan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of SydneySusan Wakil School of Nursing & Midwifery, and Site Services, University of Sydney Library, University of SydneyCollege of Medicine and Public Health, Flinders University of South AustraliaLeeds Institute of Cardiovascular and Metabolic Medicine, University of LeedsDepartment of Medicine, University of Toronto, St Michael’s HospitalCanadian VIGOUR Centre, Department of Medicine, University of AlbertaSusan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of SydneySchool of Health Sciences, Faculty of Medicine and Health, University of SydneyConcord Clinical School, Concord Repatriation General Hospital, ANZAC Research InstituteAbstract Background Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings. Methods Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model. Results Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors. Conclusions Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally.https://doi.org/10.1186/s12913-022-07750-8Acute coronary syndromesGRACE Risk ToolImplementationImplementation fidelityProcess evaluationRisk stratification |
| spellingShingle | Janice Gullick John Wu Derek Chew Chris Gale Andrew T. Yan Shaun G. Goodman Donna Waters Karice Hyun David Brieger Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation BMC Health Services Research Acute coronary syndromes GRACE Risk Tool Implementation Implementation fidelity Process evaluation Risk stratification |
| title | Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation |
| title_full | Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation |
| title_fullStr | Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation |
| title_full_unstemmed | Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation |
| title_short | Objective risk assessment vs standard care for acute coronary syndromes—The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation |
| title_sort | objective risk assessment vs standard care for acute coronary syndromes the australian grace risk tool implementation study agris a process evaluation |
| topic | Acute coronary syndromes GRACE Risk Tool Implementation Implementation fidelity Process evaluation Risk stratification |
| url | https://doi.org/10.1186/s12913-022-07750-8 |
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