Abstract

Context
This improvement project was set in Lincolnshire, a large rural county in the East Midlands with high prescribing rates of hypnotic drugs compared with the rest of England. Eight general practices volunteered to participate in a Quality Improvement Collaborative (QIC) designed to improve management of sleep problems in patients presenting to primary care.

Problem
Sleep problems are common affecting around 40% of adults in the UK. Insomnia has considerable resource implications in terms of disability, impaired quality of life and health service utilisation. Up to half of individuals with Insomnia seek help from primary care and hypnotic drugs are often inappropriately prescribed for long term use. Non-pharmacological treatment measures are rarely implemented in practice despite guidance supporting their use. A lack of training as well as limited availability of resources for effective sleep assessment and treatment in primary care are possible explanations for this. It is clear that there is considerable scope for improving management of sleep problems in general practice

Assessment of problem and analysis of its causes
We used a Quality Improvement Collaborative to introduce practitioners to sleep assessment tools including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI) and Sleep Diaries and non-pharmacological interventions such as Cognitive Behavioural Therapy for Insomnia (CBTi). Practitioners from participating practices were asked to begin using these where appropriate within their day to day practice.

Strategy for change
The project team met bi-monthly with practice teams to share learning. We used adult learning techniques to promote rapid experimentation (Plan, Do, Study, Act) cycles, process redesign and monthly feedback of prescribing rates and costs of hypnotic drugs using statistical control charts. Data were collected from the collaborative meetings to understand the facilitators, barriers and changes that practices were making as a result of the Quality Improvement Collaborative (QIC).

Measure of improvement
Qualitative data were collected via audio recordings of practice and collaborative meetings with practitioners and practice staff. This data was then transcribed verbatim. Thematic analysis was carried out supported by computer software MaxQDA using a framework method. Nine themes emerged which were then reviewed by five members of the evaluation steering group to assess inter-rater reliability of the themes. We used statistical process control charts and an interrupted time series design to analyse prescribing data for the two year period preceding the establishment of the collaborative and for the six months of its operation.

Effects of changes
There was a significant reduction in hypnotic prescribing of benzodiazepines and Z drugs in the practices over the six months of the project and this improvement has been sustained since the initiative.
Nine themes emerged from the qualitative data: -

 Engagement of staff: Most practitioners showed enthusiasm to incorporate changes in their practice and encouraged other members of the practice to become involved by demonstrating use of the tools and reminders during meetings

“It’s brought up at every practice meeting and so it’s always fresh in people minds. It’s not something that’s then forgotten.”

 Practitioner views of the tools: Practitioners tried the tools and techniques and overall seemed to favour the Sleep diary and Insomnia Severity Index (ISI) over the Pittsburgh Sleep Quality Index (PSQI)

“Generally we found that the ISI was easy to complete, score and interpret and can be used in general practice”

 Practitioner preconceptions: Practitioners came with preconceptions about the feasibility of sleep tools and techniques. Patients’ age and intellect were factors that practitioners thought might affect whether tools were completed correctly or at all.

 Needs & educational needs of patients & staff: Before this project hypnotics had been seen as the solution to most sleep problems by both patients and practitioners.

“When people come in it was so easy to give them a prescription”

"As GPs we’re overly limited and actually to have a slightly more sophisticated response would actually be better for us but also for the patient”.

 Barriers to implementing tools & techniques: This related to systems (of care) practitioners and patients

Systems: “Once the psychiatrist says you should have this, it is really hard as a GP to go against it because you know they say the psychiatrist has asked me to take this.”

Practitioner: “We come down to the cognitive behaviour therapy approach; it’s a bit thin on my part, we’ve not got great skills in that”.

Patient: “I think the key is also definitely how to communicate it…the minute you start even trying to approach the subject that the tablets are not really very good and what about thinking about alternative ways, they will kind of glare very rudely and be like I have been there before doc[tor]. So you have got to kind of approach it in a kind of a fresh way to make them thing they are trying something new. You have got to be a salesman’.

 Changes initiated by practices: Some practices had taken other measures to try and reduce hypnotic prescribing including implementing withdrawal programmes and limiting repeat prescriptions which let to improvement is patient and practitioner experience

 GP-Patient treatment & expectations: Practitioners revealed what they thought patients expected and made suggestions of how consultations could be improved to meet patients’ needs and increase successful outcomes from a sleep consultation.

 Importance of tailored approach: Each patient with Insomnia would need to have their treatment tailored to their individual requirements therefore every consultation could potentially have very different solutions

 Lack of feedback from patients: Receiving feedback from patients was difficult for some practitioners when patients didn’t return for their follow-up consultation or didn’t complete and return their sleep assessment tools. This lead practitioners to feel unsure as to whether patients had read and absorbed the information provided to them

Lessons learnt
Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care and patient and practitioner experience

Message for others
Quality improvement collaboratives benefit from careful analysis using qualitative as well as quantitative methods.

Further information
www.restproject.org.uk
Project manager: michelle.tilling@lpct.nhs.uk
Project lead: nsiriwardena@lincoln.ac.uk