Table 4 Fidelity of delivery, receipt and enactment for each intervention component

Audit and Feedback

Audit and Feedback reports

Delivery: reports were sent by post and email every 3 months and taken to outreach meetings

Computerised searches

Delivery: organisation group on SystmOne - Practices were sent an email inviting them to join the organisation group to access the searches at any desired time.

Alternately used as part of additional support from outreach facilitators

Significant Event Audit Forms (for anticoagulation and risky prescribing practices only)

Delivery: post and email with reports, and at outreach visits

All practices: Emails were tagged with “delivery” and “read” acknowledgement requests

Fidelity survey asked staff to indicate if they received and read forms, and discussed them in their teams

Outreach facilitators checked whether audit and feedback forms had been received (and recorded on structured logs)

Process evaluation practices only: Researcher noted receipt and awareness of audit and feedback forms, observing where they were seen in practices and exploring practice staff views on the reports in one to one conversation and post-trial group feedback

All practices: Computer system tracked whether or not the practices joined the organisational group and downloaded the searches. Outreach facilitators logged use of searches as part of additional support. Fidelity survey asked practices whether they were aware of and used the searches

Process evaluation practices: researcher observed use of searches and spoke to practices in post-trial group feedback about the usefulness of searches

All practices: Delivery tracked when delivered with audit reports or outreach visits (by outreach facilitators)

Process evaluation practices only: researcher observed practices and asked practice staff about awareness and engagement with significant event audit forms.

All practices received reports, as tracked by email delivery and fidelity survey data

Process evaluation noted variation in how reports were shared and used within practices (e.g. practice managers not sharing reports widely; only some practices discussing reports at meeting).

126 practices (87.5%) joined the organisational group and therefore could access searches.

In the fidelity survey, 75% of trial and process evaluation practices stated they had used the searches.

Receipt not specifically tracked in the trial practices, beyond delivery of reports and outreach visit.

Searches were made use of in some process evaluation practices (for risky prescribing and anti-coagulation; infrequently for blood pressure and diabetes)

In the relevant four process evaluation practices, there was evidence of receipt in one practice but no evidence of receipt or use in the others

Educational outreach meetings and additional support

Delivery: personal visit to practice by outreach facilitator; offer made by phone and on each feedback report

Maximum of two educational outreach visits were offered to each practice

All practices: Outreach facilitators completed structured logs recording who attended the training and their job roles. They also recorded which practices took up offer of additional support.

Fidelity survey asked practices if they took up the offer of outreach support.

Process evaluation practices only: Researcher noted receipt and awareness of outreach support, and asked staff about their engagement and the value of outreach meetings and support in one to one conversations and post-trial group feedback

Sixty-seven (47%) trial practices and seven (87.5%) of process evaluation practices received one outreach meeting.

Reasons given for not taking up outreach offer: Trial practices declined because they were not interested, too busy or felt it was not needed. One anticoagulation process evaluation practice declined because they felt confident to do the work without outreach meeting.

Additional support was taken up by 16 (24%) trial practices and five process evaluation practices. Most support was delivered remotely in the form of running searches, reviewing patient notes, and creating recommendations for management. Awareness of additional support was low in process evaluation practices (usually 1-2 staff members being aware of it).

Eight (5.6%) trial practices and three process evaluation practices received a second visit, another requested a visit but this could not be accommodated before trial end.

Significant delays noted in delivering outreach visits to practices.

Reminders

Computerised prompts (available for risky prescribing only)

Delivery: organisation group on SystmOne - Practices were sent an email inviting them to join the organisation group to access the prompts at any desired time.

All practices: Computer system tracked whether or not the practice downloaded the prompts

Fidelity survey asked practices if they used the prompts

Process evaluation only: researcher asked staff about their awareness and engagement with the prompts

Eight (32%) trial practices and both process evaluation practices downloaded the risky prescribing protocol

Evidence from process evaluation practices that the prompts were considered useful by one practice as they enabled greater involvement of staff typically not involved in risky prescribing decisions.