Of the 35 requested GPs, 9 consented to participate (response rate: 26%); 7 participated in individual interviews and 2 in the focus group interviews. Of 14 PTs requested, 8 consented to participate (response rate: 57%). Among those, 6 participated in individual and 2 in focus group interviews. A total of 9 nurses were requested and 7 participated (response rate: 77%); 5 in individual and 2 in focus group interviews. Reasons for non-participation were holidays, lack of time or staff shortage.
In total, 17 health professionals (7 GPs, 6 PTs, 5 nurses) participated in individual interviews. Most individual interviews were conducted via telephone to participants being in their institution or at home (n=16, 94%), only one PT preferred a face-to-face interview at study centre. Interviews lasted 11 to 29 minutes. Characteristics of health professionals are shown in Table 1.
Table 1 Characteristics of health professionals participating in individual interviews
|
GPs
(n = 7)
|
PTs
(n = 6)
|
Nurses
(n = 5)
|
Age (Mean ± SD
(Range))
|
58.7 ± 7.87 (42 – 66)
|
42.0 ± 10.71
(28 – 58)
|
43.2 ± 11.05
(31 – 55)
|
Sex (female / %)
|
3 / 43%
|
5 / 71%
|
3 / 60%
|
Years of favour occupation (Mean ± SD
(Range))
as community nurse (Mean ± SD
(Range))
|
30.0 ± 8.04 (14 – 37)
n.a.
|
18.3 ± 10.39
(6 - 36)
n.a.
|
20 ± 5.87
(15 – 30)
12.8 ± 10.85
(1 – 27)
|
Weekly hours with patients (Mean ± SD
(Range))
|
n.a
|
34.8 ± 8.21
(6 – 36)
|
30 ± 21.11
(1 – 60)
|
GPs = General practitioners; n.a. = not assessed; PTs = Physical therapists; SD = Standard deviation.
|
GP-perspective
GP´s see their role as gatekeepers and complain that it is difficult to act in this role after the patient has been referred to a specialist. An ideal patient trajectory was described to be efficient, fast and comprising a diagnostic work up in a multidisciplinary center and involving a broader treatment approach including psychological coaching and social interventions, such as pensioners´ exchange or multi-purpose associations hanged up in a GP-practice.
PT-perspective
From the PT perspective, the most relevant problem was that referrals from GPs are mostly without proper information of the physicians’ diagnostic results and PTs have to identify patients’ problems without this information. It turned out that, even though, a specific German indication key (SO3 - physical therapy with indication for dizziness of different origins and aetiology) is not used by the GPs.
“I think they (the GPs) are hardly informed about what they can assign to what kind of patients (…) I can remember only one patient (…) coming with this (…) indication key (…). All other (patients are assigned concerning) cervical spine.” (PT, interviewee 4).
PTs reported mixed trust in their abilities to treat VDB patients, whereas they identified their knowledge from vocational training as less relevant but use skills acquired for additional trainings. Interdisciplinary communication, especially with GPs, was rated as insufficient and assumed that therapy reports were hardly read by GPs. A structured approach to and tailored for VDB patients was considered to be helpful:
“For certain things sometimes exist very clear and beautiful guidelines, like a catalog where you choose (…) I have a tree (…) something like a decision tree, exactly.” (PT, interviewee 2)
More specific educational training for PTs, interdisciplinary cooperation and patient information was rated to be beneficial.
Nurses’ perspective
From the perspective of community nurses, a main problem is to find PTs which are available for home visits. It was also criticized, that interdisciplinary communication is hampered by missing reimbursement or financial incentives. The ideal would be an interdisciplinary documentation system.
“They should document or record everything. Either that there is a kind of online portal, that would of course be the easiest. That means, where you can exchange information about the patient and (.) where everyone can write something there or in the documentation folders on site. In the end, that's just a minute that you write in there.” (Nurse, interviewee 14).
In addition, specific educational training for nurses, and programs to promote a fast support of affected people was identified to be helpful.
Group interviews with health professionals
To address the issue of multi-professional communication and to identify supportive and hindering factors, we conducted inter-professional focus group interviews among health professionals involved in primary care of VDB patients: GPs, PTs and nurses.
Study design, recruitment, data collection, analysis
Of the 35 requested GPs, 23 were interested and 9 consented to participate (GPs´ response rate: 26%); 7 in individual interviews and 2 in the focus group interviews. In PTs, 14 were requested, 14 interested and at least 8 consented to participate (PTs’ response rate: 57%); 6 in individual interviews and 2 in focus group interviews. 9 nurses were requested, 8 were interested and 7 participated (nurses’ response rate: 77%); 5 in individual interviews and 2 in focus group. Reasons for non-participation were holidays, lack of time or personnel.
Participants gave their written agreement prior to the date of interview. The interviewers had a clear structured guideline with defined main questions and examples for requests and so tried to systematically moderate the interviews. Interviews were audio-recorded and field notes were taken. Afterwards, the audio records were transcribed verbatim according to the rules of Kuckartz (19) with transcription software F4 (https://www.audiotranskription.de/f4). Two researchers (VR, ES) independently carried out a first draft of a coding tree using MAXQDA software (https://www.maxqda.de/) and then discussed differences. Subsequently, VR and ES coded the material and included field notes into analysis. Data saturation was defined as the point, when no additional information was obtained.
Results of multidisciplinary focus group interviews with health professionals
Two focus group interviews with one GP, PT and nurse each were carried out for a duration of 53 minutes each. The focus group interviews were conducted face-to-face. Characteristics of the health professionals are shown in Table 2.
Table 2 Characteristics of participants of the focus group interviews
|
FG 1
|
|
FG 2
|
|
GP
(n=1)
|
PT
(n=1)
|
Nurse
(n=1)
|
|
GP
(n=1)
|
PT
(n=1)
|
Nurse
(n=1)
|
Age (years)
|
68
|
50
|
55
|
|
66
|
27
|
31
|
Sex (m / f)
|
m
|
m
|
f
|
|
m
|
f
|
f
|
Years of favour occupation (years)
as CN (years)
|
40
n.a.
|
25
n.a.
|
25
n.s.
|
|
41
n.a.
|
8
n.a.
|
7
4
|
Working hours per week (%)
|
110
|
100
|
70
|
|
130
|
100
|
100
|
f = Female; FG = Focus group; GP = General practitioner; m = Male; n.a. = not assessed; n.s. not stated; PT = Physical therapist.
|
It was mentioned that an important barrier for good multi-professional and patient-centered communication is that there is no additional reimbursement for such activities. It was mentioned as critical that GPs do not have a central gate keeper role when the first contact point of a patient was a medical specialist. Knowing each other personally was identified as the most relevant facilitator of good cooperation, e. g when GPs or PTs are organised in centres. Space for potential improvement is seen in the communication between GPs and PTs, especially in terms of interdisciplinary cases conferences where video conferencing and digital shared online documentation was seen as potentially helpful.
“I think the online portal is the one thing that could best be realized. (…) time is relatively tight (…) you don't have to sit down together, you can actually do it online. And then maybe just write to me. So I find that feasible now.” (Nurse, interviewee 1)
“So I think team meetings are less feasible because the different times can never be brought together (…) it is of course also unpaid time. (…) the basis could be an electronic document (…) and 80% can then be resolved (…) and the rest, you are (…) on the phone. (GP, interviewee 1)
In summary, the optimal health care strategy for older VDB patients was described as long-term, continuous and target-group-specific.
Individual interviews with patients
To identify conditions of successful CPW implementation by integrating the consumers’ perspective (experiences regarding accessibility and availability, expectations, motivation and beliefs) into development process we conducted individual interviews with affected people.
Study design, recruitment, data collection, analysis
We included patients aged at least 65 years old which consulted a GP with complaints of VDB. Additionally, we recruited patients in PT practices, which are already enrolled in PT programmes. Patients were all approached, putting up a poster in PT practices to recruit affected people and providing our telephone number for further information in case of interest. Patients became aware because of their PT or relatives/acquaintance. Exclusion criteria were patients aged under 65 years or getting a serious condition/disease, requiring hospital treatment, wishing to be excluded from the study. Additionally, we investigated the impact of VDB symptoms on the patients´ activities of daily living and social participation using the German version of the vertigo activities and participation questionnaire (VAP) (20).
Participants gave their written agreement prior to the date of interview. The interviewers had a clearly structured guideline with defined main questions and examples for requests and so tried to systematically moderate the interviews and minimize inter-interviewer reliability. Interviews were audio-recorded and field notes were taken during all interviews. Afterwards, the audio records were transcribed verbatim according to the rules of Kuckartz (19) with transcription software F4 (https://www.audiotranskription.de/f4). Two researchers (VR, ES) independently carried out a first draft of a coding tree using MAXQDA software (https://www.maxqda.de/) and then discussed differences. Subsequently, VR and ES coded the material and included field notes into analysis. Data saturation was defined as the point, when no additional information was obtained. For the VAP questionnaire we calculated descriptive statistics.
Results of individual interviews with patients
A total of 14 patients contacted the study centre because of interest and 11 consented to participate (patients’ response rate: 79%). Reasons for non-participation were lacking interest or time.
In total, 11 patients participated in individual interviews which were conducted via telephone (n=10; 91 %); only one patient preferred a face-to-face interview at the study centre. In some cases, the partner joined at the telephone interview due e.g., hearing loss. Interviews lasted 13 to 33 minutes. Characteristics of participants are shown in Table 3.
Table 3 Characteristics of patients participating in individual interviews
|
Patients
(n = 11)
|
Age (Mean ± SD
(Range))
|
75.5 ± 6.9
(65 – 89)
|
Sex (female / %)
|
7 / 64%
|
Symptoms (n / %):
Dizziness
Balance disorder
Gait instability
Fall history
Other additional symptoms
|
9 / 82%
4 / 36%
10 / 91%
8 / 73%
6 / 55%
|
SD = Standard deviation.
|
Some patients reported not to have consulted any physician because they considered symptoms as not so serious or it was due to lack of time. From the patients’ perspective, optimal health care is when symptoms are taken seriously by GPs and are not only attributed to ageing, and includes continuous PT, home training, usual and alternative therapy approaches, medication, age specific offers or group sessions.
Interviewers´ characteristics
The two researchers ES and VR (both master’s degree and vocational training as health professionals) conducted the interviews and the study assistant wrote the protocols. Both interviewers were trained how to develop an interview guideline and perform interviews by a separate qualitative workshop and had further experience out of prior research activities. No relationships were established with participants prior to study commencement. All participants were informed about data privacy and about the intentions of doing this research previously.
Step 2: Modelling
Expert workshop
Study design and recruitment
The expert workshop was planned as a three-day event in a closed setting to create a productive and focused working space. An external moderator was introduced to the subject and process of the expert workshop. Recruitment of experts was conducted in order to cover every area of getting the affected individual in touch with during the process of care. Therefore, we brainstormed potential involved persons following the International Classification of Functioning, Disability and Health (ICF) rehab-cycle (21) as a basic theory of structuring the patient´s rehabilitation process and characterizing steps of involved health professionals. In addition to the participants of the interviews, we identified health professionals as clinical experts, representatives of health insurances, of health care research and of affected individuals.
To recruit, collaboration partners and local practices/institutes were contacted. Recruitment of representatives of health insurances was conducted via personal contacts. We re-recruited interview partners and used member lists of the Association of Statutory Health Insurance Physicians. Due to loss of earning for self-employed persons by participating in our workshop, a remuneration was paid.
Methods of the workshop
At the expert workshop, a step-wise modelling process was conducted (see Figure 3). First, an update on recent disease-specific knowledge was given by a senior medical doctor and methodologic introduction in CPWs by a health care researcher. This was necessary to start with a common basic knowledge among the participating experts. Then, results of prior research were presented by the research team and accompanied by factsheets: Results of existing evidence (systematic reviews) and of health care providers´ and consumers´ perspective (interviews). To guide experts through different stages of the modelling process various creative techniques in plenary, alone and in small groups, were used. Good evidence exists for the Consolidated Framework of Implementation Research (CFIR) (22) and Expert Recommendations for Implementing Change (ERIC) (23) as well as a matching tool of both to systematically identify potential barriers/facilitators and select implementation strategies of interventions. The frameworks were translated into the German language and translation will be published elsewhere. In conclusion, milestones and an implementation plan were defined.
Results of the expert workshop
The expert workshop was conducted for three days in October 2018. Response rate of clinical experts, researcher and representatives of affected people and insurances were 50% to 100%. We had problems to recruit GPs (response rate: 0.1%): Recruiting regional GPs, response rate was 14% (1 participating GP out of 7 requests), but re-recruiting interview partners (9 requests) and using member lists of the Association of Statutory Health Insurance Physicians (124 requests) was 0%. In total, 9 clinical experts (2 neurologists, 1 ENT physician, 1 GP, 3 PTs, 1 geriatric nurse, 1 medical assistant), 2 experts in health care research, 2 health insurance representatives, 2 patient representatives participated.
First version of CPW
Experts drafted a first version of the CPW according to the steps of ICF Rehab-Cycle (21). Regarding access, a hotline for patients and population-related informing was recommended. This version included tools for health professionals in order to screen, assign, treat and evaluate VDB patients and should promote multi-disciplinary communication between all involved HPs.
Implementation strategy
Potential barriers and facilitators
Weighting potential barriers and facilitators according to CFIR (22) the most prioritized construct was the inner setting (44 points; 39%), followed by intervention characteristics (26 points; 23%), processes (18 points; 16%), characteristics of individuals (17 points; 15%) and outer setting (7 points; 6%) (see Figure 4, for detail see Table 4).
Implementation strategies
After transformation of these barriers using the matching tool software, a weighted order of matching ERIC strategies was present and the 15 most important strategies were further elaborated (see Table 4).
Table 4 Potential barriers and matched implementation strategies
CFIR
|
1
|
ERIC
|
Priority
|
Construct
|
Barrier
|
Priority
|
Strategy
|
1.
|
Intervention characteristics
|
Cost
|
1.
|
Identify and prepare champions
|
2.
|
Inner setting
|
Organizational Incentives & Rewards
|
2.
|
Alter incentive/allowance structures
|
3.
|
Characteristics of individuals
|
Knowledge & Beliefs about the Intervention
|
3.
|
Assess for readiness and identify barriers and facilitators
|
4.
|
Processes
|
Reflecting and evaluating
|
4.
|
Conduct local consensus discussions
|
5.
|
Inner setting
|
Implementation climate
|
5.
|
Inform local opinion leaders
|
6.
|
Inner setting
|
Available resources
|
6.
|
Conduct educational meetings
|
7.
|
Processes
|
Planning
|
7.
|
Access new funding
|
8.
|
Intervention characteristics
|
Evidence strength & quality
|
8.
|
Capture and share local knowledge
|
9.
|
Outer setting
|
External policy & incentives
|
9.
|
Conduct local needs assessment
|
10.
|
Characteristics of individuals
|
Individual stage of change
|
10.
|
Develop a formal implementation blueprint
|
11.
|
Intervention characteristics
|
Relative advantage
|
11.
|
Audit and provide feedback
|
12.
|
Inner setting
|
Tension for Change
|
12.
|
Build a coalition
|
13.
|
Inner setting
|
Goals and Feedback
|
13.
|
Develop and implement tools for quality monitoring
|
14.
|
Inner setting
|
Leadership Engagement
|
14.
|
Identify early adopters
|
15.
|
Involve executive boards
|
CFIR = Consolidated framework for implementation research; ERIC = Expert recommendation for implementing change.
|
Milestones and implementation plan
The implementation plan with milestones for the subsequent study were discussed and consented to by the experts. Regarding access, recruitment of potential study participants should be conducted by GPs using clear inclusion criteria for patients. Assessment and assignment should be conducted by the GPs using a screening tool with accompanied and credited educational training. To evaluate the effectiveness of the (assigned) intervention, specific follow-up times are recommended. For detail see Table 5.
Table 5 Steps of the CPW and milestones of its implementation
Steps of the CPW
|
Milestones
|
Access:
- Immediately
- Direct
- Involvement of relatives
|
® Reaching of the pre-defined number of participating GPs and patients
|
Assessment:
- Central role of GP
- Checklist
- Educational training of GPs
|
® Development of a screening tool
® Accompanied previous educational training of GPs
|
Assignment:
- Prompt
- Physical therapy as favoured intervention
- Organized in a network
- Case managers
|
|
Intervention:
- Capacity of providers
- Treatment duration
- Involvement of additional potential actors
- Extended offer of providers (e.g., clubs, community college)
|
® Recruitment of collaboration partners
® Educational training of PTs
|
Evaluation:
- Feedback to all involved actors
- Follow-up appointments in checklist
|
|
CPW = Care pathway; GPs = General practitioners; PTs = Physical therapists.
|
Subsequent modelling design and implementation of CPW
CPW, intervention components and educational training materials
Modelling process of design
Results of the expert workshop were collected, reviewed and analysed. According to defined milestones, a checklist for GPs and a guide for PTs with accompanied educational trainings were developed. In two expert meetings with a GP, one neurologist, one neuro-otologist and 1 ENT physician, we modelled a more detailed version of GP’s part in the CPW in an iterative way. Subsequent to each of the two face-to-face meetings, feedback and further exchanges via telephone or email with the research team was done if necessary. Based on the ICF-Rehab-Cycle and its process of care as well as literature of evidence-based practice (24) the research team developed a first draft of an algorithm for the PT-guide. In telephone contacts with 3 renowned PT specialists an enhanced version was adopted.
CPW
The developed multi-disciplinary CPW is a paper-based algorithm, that illustrates all steps of the aged patients’ path in a structured way (see Figure 5). Specific sub-processes of the CPW are a checklist for GPs and a guide for PTs.
GP-checklist
The screening checklist for GPs that manage patients with VDB aims (a) to exclude life-threatening conditions (b) to promote reliable diagnosis and evidence-based treatment by GPs and (c) to ensure a rational referral regime. The final checklist is a paper-based algorithm and consists of aspects of anamnesis, assessments, specific referral regimes and assignments to therapy and follow-up timelines for consultation. The checklist is not available since it is not evaluated for effectiveness and safety so far. The educational training aims to develop an in-depth understanding of the checklist and exercises.
PT-guide
An evidence-based guide for clinical reasoning and treatment for PTs focusing the leading symptom chronic dizziness and balance disorders. The guide is not available since it has not been evaluated for effectiveness and safety so far. The guide is also not available. The guide contains guidance on anamnesis, assessment, treatment and evaluation. Regarding anamnesis, background information about clinical pattern was included. The decision tree style leads to specific assessments and treatment options. Additionally, educational flyers and leaflets were included to be handed out to patients during the therapy: 4 educational leaflets about practical exercises (physical therapy for balance disorders, gait disorder, vertigo as well as instructions for the positioning manoeuvre of posterior canal benign paroxysmal positional vertigo) provided from collaborating with the German Centre for Vertigo and Balance Disorders and 2 informational flyers that were translated from existing literature into the German language. These include topics like symptom control of vertigo and nausea (25) and frequently asked questions about benign paroxysmal positional vertigo (26) using the American clinical practice guideline (27).
To ensure correct and confident application of the guide including assessments and interventions, educational training was performed. Prior to the training, informational material, in order to prepare the participants and ensure a common base of knowledge, was provided.
Implementation strategy of the CPW
Modelling behaviour change
We conducted a step-wise approach to intervention design and implementation strategy using the guide to approach the Behaviour Change Wheel (BCW) (28). We also took identified barriers and facilitators according to CFIR (22) and matched implementation strategies according to ERIC (23) from our expert panel in consideration. In an iterative way, we moved between the BCW and CFIR/ERIC. These frameworks helped to organize and develop specific behaviour change techniques and implementation strategies. To design behaviour change, we conducted the 7 steps of the guide using the provided worksheets (see Additional file 1). We applied the Capability-Opportunity-Motivation-Behaviour (COM-B) model and Theoretical Domains Framework and used potential barriers according to CFIR and ERIC strategies from our expert workshop.
Implementation strategy
As a result, behaviour change of health professionals is needed to apply evidence-based checklists or guides. The implementation strategy comprises an face-to-face educational training in groups, accompanying information or instruction manuals and social support by mentoring during the first phase of applying providing a phone helpline at an individual-level. A material incentive like accreditation points for educational training or case payments seemed to be useful for participation.
Logic Model of the CPW´s intervention components and implementation strategies
Development of a Logic Model
To systematically present the relationships between the intended results, the underlying mechanism of change and the planned work, we developed a logic model according to Kellogg´s Logic Model Development Guide (29). We finally checked the model for its completeness regarding context, implementation and setting with the Context and Implementation of Complex Interventions framework (17).
Logic Model
We developed a logic model using Kellogg´s Logic Model (see Figure 6) combining the findings of prior results regarding assumptions and influential factors. Since the key to practice development is behaviour change among health professionals, to define planned work, mechanism of impact (using the COM-B model, the inner layer of BCW (28)) and intended results. To improve VDB patients´ situation regarding mobility and participation, we aim to promote self-efficiency of health professionals by supporting them in behaviour change. Therefore, we plan to give them more in-depth knowledge and skills via written information and face-to-face educational trainings in how to diagnose and treat VDB patients efficiently using distinct parts of the CPW (GP-checklist and PT-guide).