Patient and provider perspectives on factors that influence the implementation of a community and hospital care bundle to improve the treatment of patients with peripheral arterial disease in primary and secondary care
Authors: Le Boutillier Clair , Saratzis Athanasios , Saha Prakash , Benson Ruth , Bridgwood Bernadeta , Watson Emma , Lawrence Vanessa 
Published: July 2022

Background

The Community and Hospital cAre Bundle to improve the medical treatment of cLaudIcation and critical limb iSchaemia (CHABLIS) study is a prospective mixed-methods study across NHS hospitals and primary care networks, which aims to determine the feasibility of using a complex intervention in the form of a care bundle, consisting of checklists, leaflets and letters, called the LEGS intervention (LEaflet Gp letter Structured checklist), to improve the care of patients with peripheral arterial disease (PAD). The aim of this qualitative study was to gain an understanding of the acceptability of the provision and delivery of the LEGS intervention, by patients, general practitioners and secondary care clinicians. Engaging stakeholders in these conversations provides insights for future intervention refinement, uptake and implementation.

Methods

This qualitative study was embedded within the CHABLIS study. Twenty-five semi-structured telephone interviews were conducted with i) patients who had received the intervention (n=11), ii) secondary care clinicians responsible for delivering the intervention (n=8), and iii) general practitioners (n=6). Data were initially analysed using inductive descriptive thematic analysis. The consolidated framework for implementation research was then used as a matrix to explore patterns in the data and to map connections between the three participant groups. Lastly, interpretive analysis allowed for refining, and a final coding frame was developed.

Results

Four overarching themes were identified: i) The potential to make a difference, ii) A solution to address the gap in no man’s land, iii), Prioritising and making it happen and iv) Personalised information and supportive conversations for taking on the advice. The intervention was viewed as an opportunity to meet patient needs, and to develop shared primary and secondary care working practices. The impetus for prioritising and delivering the intervention was further driven by its flexibility and adaptability to be tailored to the individual and to the environment.

Conclusions

The LEGS intervention can be tailored for use at early and late stages of PAD, can be provided across primary and secondary care settings, and provides an opportunity to promote shared working across the primary-secondary care interface.

Contributions to the literature

Primary and secondary care providers acknowledged the need for an intervention to support them to deliver guideline-based PAD treatment, and to target the intervention earlier in the PAD treatment pathway.

A gap was identified in terms of support for patients and providers between the time of diagnosis of early-stage PAD (e.g., claudication) and a subsequent potential diagnosis of advanced PAD. The LEGS intervention can be used to fill this gap by enabling providers to support patients to receive help, education, support, or appropriate medication to address their condition.

Patient-provider interactions that promote shared decision-making and that support patient preference are also important determinants in the success of implementation.