Participants
During a twelve-month period, 47 GPs were successfully included in the intervention arm of our cluster-randomized effectiveness study, and had access to our ePrimaPrescribe DBCI platform. We collected data from onsite questionnaires that were completed by 37 intervened GPs. Sixty-eight percent of respondents to this questionnaire had used the DBCI platform and 72% were prescribers at USF primary health care units. The respondents’ mean age was 47 years old. The mean years of clinical experience was 20 and 57% of GPs had at least some specific training in mental health (Additional file 1).
The BaFAI was completed by 24 GPs included in the intervention arm, and by 17 GPs included in the control arm of our cluster-randomized effectiveness trial. We found that most respondents were prescribers at USF type primary health care units; that the mean age was 46 years old; the years of clinical experience varied from 4 to 18; and that there was a balanced distribution of responders with and without training in mental health (Additional file 2).
We interviewed 12 GPs who were included in the intervention arm of our effectiveness cluster-randomized trial. Of the total interview participants, 58% were prescribing in USF type primary health care units. Fifty-eight per cent of respondents were male and 58% had effectively used the platform. The mean age was 54 years-old and the mean number of years of clinical practice was 27. Our sample was balanced for previous training in mental health (Additional file 3).
We chose to report the perspectives that were more significant and consistent across the different data sources.
There was a high degree of motivation to participate in the study when it began, which had decreased by the end of the study. The majority of respondents had actively used the DBCI platform, and they considered its implementation feasible, both at the beginning and at the end of the study. At the beginning of the study, the participants considered that the platform would have an impact on changing their BZD prescribing patterns, but the number of GPs reporting this impact significantly decreased by the end of the study (Table 1).
Table 1: Results from the onsite questionnaire multiple answer questions
|
t0
|
t12
|
Fisher exact test
|
q11 - Degree of motivation to participate in this study
a) None
b) Little
c) Some
d) A lot
|
0 (0%)
0 (0%)
22 (59,46%)
15 (40,54%)
|
0 (0%)
8 (32%)
14 (56%)
3 (12%)
|
p=0,614
|
q16 - Do you think it is feasible to implement online training programs like ePrimaPrescribe?
a) yes
b) no
|
35 (94,59%)
2 (5,41%)
|
29 (87,88%)
4 (12,12%)
|
p=0.121
|
q18 - Do you consider that the use of the ePrimaPrescribe platform will have an impact on changing your benzodiazepine prescription pattern?
a) yes
b) no
|
36 (100%)
0 (0%)
|
16 (69,57%)
7 (30,43%)
|
p= 0.138
|
When asking about the main motivations and expectations regarding compliance with the implemented DBCI, two themes were mentioned more frequently: knowledge acquisition and practice improvement. Some participants reported that the DBCI made them more aware of the need to make a deep reflection about the consequences of their clinical behaviour, in this case, specifically their prescribing patterns.
Both at baseline and at the end of intervention implementation, the lack of time was mentioned as one of the most important factors limiting CME implementation, regardless of it being online or onsite (Table 2). In fact, implementation of the online format was mentioned as being more significantly affected by the time factor, since its utilization had to occur outside of office hours. Despite most GPs having 15 days a year granted for CME, most mentioned that this time was not actually available to be used, due to work overload and the difficulty of rescheduling the excessive number of patients and appointments that would accumulate after a period of absence to comply with CME.
"the excess work we have, I can't afford the luxury of taking off the fifteen days of training we're entitled to a year, isn't it, for, for the free service commission, I can't take them off, because I can't, simply. I don't have anywhere to refer my patients appointments [if I’m on a leave]” (Interviewee 2, female, 39 years old, 9 years of clinical practice, with mental health training, prescribing at an UCSP primary health care unit, used the ePrimaPrescribe DBCI platform)
Work overload, which led GPs to attempt to do many things at the same time because of the limited time they had to fulfil the different tasks they are expected to perform, was referred as anxiogenic. GPs expressing this perception ended up not even trying to use the DBCI, thus demonstrating how the lack of time and its effect on participants’ emotions directly influenced intervention implementation.
Work overload
As a barrier to CME implementation, GPs mentioned feeling overwhelmed by their need to receive training in too many different areas, since they are first in line as primary medical care physicians and patients come with very different complaints. Moreover, they also mentioned the fact that they face excessive bureaucracy in their role, leaving little time for training or further studying. In some ways, the GPs’ underlying GPs discourse translates into frustration over the impossibility of “doing it all”.
"The fields of Family Medicine are many, many, and, and therefore it is difficult to maintain continuous training in, in cardiology, in diabetes, in child health, in, 'you see, in mental health, in, it's this, that, the other. So I think, hmm, they're a lot, they move in many areas at the same time, don't they?” (Interviewee 5, male, 67 years old, 40 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
Digital competence
Barriers related to skills were also mentioned, such as lack of digital know-how because of age. Senior GPs found digital tools challenging due to a lack of knowledge regarding new technologies and long-term working habits. Younger professionals reported being more prone to using digital tools than senior ones.
“Because I always have to look at a lot of things on the computer, uh, I'm not an individual who has much experience in using computers and it bothers me a bit to be watching, having to look at the screen” (Interviewee 6, male, 64 years old, 30 years of clinical practice, with mental health training, prescribing at an UCSP primary health care unit, used the ePrimaPrescribe DBCI platform)
“I might prefer things online, because I can access it more easily” (Interviewee 8, male, 31 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
Digital infrastructure
Technical issues, such as bad internet connection and lack of sound devices were mentioned as significantly influencing implementation of our DBCI platform (Table 2). The lack of proper hardware at primary health care units to use digital platforms (proper internet connection, or computers’ configuration) was pointed to as an important barrier, even when the GP had a high motivation to comply with CME. This was exemplified by a case where the GP chose to print the content of the DBCI because he could not access the platform during office hours.
“I tried to get into USF X at the time…and I couldn't…and then there was no sound and then I couldn't load…and then it was blocked…and therefore, the accesses I ended up doing were at home… and then when I needed it at the I work, to clarify any doubts… I couldn't use it” (Interviewee 8, male, 31 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
Motivational and emotional factors
In general GPs reported low motivation to comply with CME, especially after their junior residency period. Senior GPs mentioned that residents (hence younger and during their compulsory residency training period) usually make an effort to comply with training, but felt that they themselves had a lower motivation level to participate, mostly due to habit and the perception of a higher work overload. These were some of the reasons pointed out by GPs to excuse a certain therapeutic inertia, particularly concerning BZD prescription and starting BZD withdrawal schemes.
"I understand that older or less patient colleagues no longer have the...motivation to do this type of training" (Interviewee 8, male, 31 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
“I don't have much patience anymore because I'm going to retire after year!” (Interviewee 10, female, 64 years old, 38 years of clinical practice, without mental health training, prescribing at an USF primary health care unit, did not use the ePrimaPrescribe DBCI platform)
The influential factors regarding motivation ranged from problems with changing old routines (Table 2) and therapeutic inertia, to a lack of self-discipline and laziness. GPs related these factors to their difficulty in setting limits between work and leisure time, once again stressing the issue of time as limiting compliance to CME. Some participants stated that a lack of interest in the specific theme of an offered CME intervention would negatively determine their compliance. The general lack of motivation led to feelings of guilt and overwhelm, with the latter being a frequently mentioned argument for non-compliance with CME.
"Afterwards, at home, few colleagues have the will or patience to go open another platform and see something else... they were and are too fed up with work to go do or think about work when they get home" (Interviewee 8, male, 31 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
"At a certain moment I realized that I was late... and, and that also made me feel a little guilty... deep down I felt that I was failing" (Interviewee 7, male, 60 years old, 33 years of clinical practice, with mental health training, prescribing at an UCSP primary health care unit, did not use the ePrimaPrescribe DBCI platform)
Facilitators
Convenience of delivery method
GPs considered that one of the main facilitators of CME implementation and successful compliance would be the convenience of its delivery method (Table 2). However, when specifying what method would be most convenient, the perspectives seemed antagonistic. Most participants mentioned that they would prefer onsite CME, arguing that they felt that they learned better in such a setting, since it was easier to stay concentrated and avoid distractions.
"The ideal would be things in person, reduced audience, and maybe with a little more frequency. That is, I don't know, every three months, every two months, talk about it...or remember, or give... training, or even if it was just once or twice a year, but with tools that you could use. I think it would be, it would be what would work out better" (Interviewee 8, male, 31 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
It was also said that onsite training, such as conferences or periodic meetings with experts, allowed GPs to escape their routine, and made it easier to establish limits between work and off-work time. Junior and senior GPs shared the preference for onsite training, although the reasons presented for this preference were different. Senior doctors mentioned preferring onsite training due to technical difficulties and personal preference; junior doctors seemed to prefer onsite training as a way of assuring the protection of their time to comply with CME.
“For me, it would always be more advantageous one, one, one training, even if it was one day a week… or two days a week that I could manage… and at that time I'm just for this… for me it's more profitable than, trying to read, because, and we would be talking to each other...” (Interviewee 7, male, 60 years old, 33 years of clinical practice, with mental health training, prescribing at an UCSP primary health care unit, did not use the ePrimaPrescribe DBCI platform)
For senior GPs onsite CME was also preferred to online due to their lack of openness to digital tools.
"I prefer one with, training with the person present...no, things on the internet, no, don't invite me" (Interviewee 10, female, 64 years old, 38 years of clinical practice, without mental health training, prescribing at an USF primary health care unit, did not use the ePrimaPrescribe DBCI platform)
Some GPs claimed advantages of an online delivery method, arguing for the feasibility of implementing CME online platforms implementation, for the ease of access to knowledge and the ease of access concerning technical aspects, such as the possibility of using it at any time according to personal availability. For these GPs, CME available online is more convenient, avoids unnecessary travel, responds to the need to be updated, and is an accessible way to improve one’s knowledge and practice. The only downside they acknowledged relating to this delivery method was, once again, to time management, since most GPs claimed they were not supposed to use their 15 days’ leave a year on this type of CME. Notwithstanding, even for GPs advocating for online CME options, it was recognized it was helpful to have an onsite presentation of digital platforms.
“It's a good option, especially for these issues of time and travel. It can even be done anywhere, anywhere…" (Interviewee 11, male, 30 years old, 6 years of clinical practice, with mental health training, prescribing at an USF primary health care unit type, did not use the ePrimaPrescribe DBCI platform)
Practical and pragmatic content
Participant GPs suggested specific content characteristics to facilitate CME implementation. Most highlighted the specificity and didactic benefits (Table 2), such as focusing on prescribing and deprescribing processes and on specific pathologies. Regarding online CME, they focused on the need for a nice interface and a simple structure.
"I think it would have to be more, uh, more practical, let's say, it would have to be a more practical training. I'm not saying that no to the issue of pharmacology and all of this, but, uh, [it should] be a thing, uh, eminently practical, with, comprehensive in relation to the various types of treatments that exist, therapies that exist, but it would be more, more practical" (Interviewee 4, male, 63 years old, 37 years of clinical practice, without mental health training, prescribing at an UCSP primary health care unit, used the ePrimaPrescribe DBCI platform)
Liaison with specialists
Many GPs mentioned that periodic meetings with experts at the primary health care units, and in general communication with practitioners with expertise, would facilitate CME implementation. They perceived this articulation as a way of complementing and accommodating new knowledge and suggested as a practical solution the implementation of a telephone line for questions and answers.
“Even sometimes, I don't know, with the patient present and we call: “look, help me here with this issue, I have this patient, like, how am I going to medicate? What am I going to do to you? She's not better, with the medication she's taking, what can she change?” Something like that” (Interviewee 10, female, 64 years old, 38 years of clinical practice, without mental health training, prescribing at an USF primary health care unit, did not use the ePrimaPrescribe DBCI platform)
Mandatory CME
As mentioned above, time was repeatedly mentioned as negatively influencing CME implementation, either through motivation or the perception of work overload. Mandatory CME was perceived by some as a facilitator to implementation and the most adequate solution to this time limitation as a transversal barrier to CME. GPs suggested that mandatory CME would secure days of training, and hence protect time for knowledge acquisition from other pressing clinical duties. It was mentioned that having protected time for CME would make GPs more compliant, regardless of the delivery method (i.e. either online or onsite CME).
“Theoretically there should be a part of our working time to, for personal training, hmm, to read articles, including distance training, which nowadays is often more practical, hmm, and more economical, hmm, in practice. Speaking for myself, I spend, um, ninety-nine percent of my professional time seeing patients" (Interviewee 7, male, 60 years old, 33 years of clinical practice, with mental health training, prescribing at an UCSP primary health care unit type, did not use the ePrimaPrescribe DBCI platform)
“I don't know, if this comment fits here. I think that, in our training, over the years, maybe there should be mandatory training, right? ...if we were somehow obligated, in quotes, I don’t mean doing training all the time, but if there were some things that were mandatory, I'm sure people would go there, would do it, whether through... of platforms, whether it was otherwise, isn't it?” (Interviewee 3, female, 64 years old, 38 years of clinical practice, without mental health training, prescribing at an USF primary health care unit, used the ePrimaPrescribe DBCI platform)
Taking into account all the factors mentioned in the examples above, the barriers to CME identified by GPs are manifold, and revel the entanglement of organizational and personal, or more subjective, factors in the perception of GPs about CME in its different possible modalities. The table below synthesizes these results, of the BaFAI questionnaire, and the globality of factors considered by GPs as barriers to CME:
Table 2: Results of the BaFAI
Factors identified as barriers
|
Intervention (n=24) (% of total)
|
Control (n=17) ((% of total)
|
Characteristics of the practice/innovation
|
|
|
The online platform leaves enough room for me to make my own conclusions - compatibility
|
1 (4%)
|
1 (6%)
|
The online platform leaves enough room to consider my patients related mental health needs – specificity
|
0 (0%)
|
0 (0%)
|
The online platform is a good starting point for my self- study – didactic flexibility/benefit
|
0 (0%)
|
1 (6%)
|
Working according to the online platform is too time consuming – time investment
|
13 (54%)
|
10 (59%)
|
The online platform does not fit into my ways of working at my practice - attractiveness
|
7 (29%)
|
6 (35%)
|
The lay-out of this online platform makes it handy for use - attractiveness
|
2 (8%)
|
4 (23,5%)
|
Barriers deriving from the characteristics of the professionals
|
|
|
I did not thoroughly use nor remember the online platform – training attitude
|
10 (42%)
|
10 (59%)
|
I wish to know more about the online platform before I decide to apply it - innovation doubts
|
8 (33%)
|
10 (59%)
|
I have problems changing my old routines. motivation and role
|
10 (42%)
|
10 (59%)
|
I think parts of the online platform are incorrect perception knowledge
|
0 (0%)
|
0 (0%)
|
I have a general resistance to working according to protocols participation
|
3 (12,5%)
|
3 (18%)
|
Fellow doctors (GPs) do not cooperate in applying the online platform - involvement
|
3 (12,5%)
|
7 (41%)
|
Other doctors or assistants do not cooperate in applying the online platform - involvement
|
2 (8%)
|
4 (23,5%)
|
Primary health care coordinators do not cooperate in applying the online platform - involvement
|
3 (12,5%)
|
4(23,5%)
|
It is difficult to apply the ePrimaPrescribe platform ... because I am not trained to use online platforms – work style
|
2 (8%)
|
2 (12%)
|
Barriers due to patient characteristics
|
|
|
Patients do not cooperate in applying the online platform readiness to change
|
8 (8%)
|
3 (18%)
|
It is difficult to apply the ePrimaPrescribe platform to patients due to ethnicity - characteristics
|
4 (17%)
|
4 (23,5%)
|
It is difficult to apply the ePrimaPrescribe platform to patients of low socio-economic background - financial situation
|
5 (21%)
|
2 (12%)
|
It is difficult to apply the ePrimaPrescribe platform to older patients (>65 years old) age
|
6 (25%)
|
3 (18%)
|
It is difficult to apply the ePrimaPrescribe platform to patients that rarely come to the primary health care unit - number of patient
contacts
|
15 (62,5%)
|
6 (35%)
|
Barriers arising from the intervention context
|
|
|
Working according to this online platform requires financial compensation
|
1 (4%)
|
1 (6%)
|
It is difficult to apply the ePrimaPrescribe platform if there is not enough supportive staff - support staff
|
3 (12,5%)
|
4 (23,5%)
|
It is difficult to apply the ePrimaPrescribe platform if the instruments needed are not available - equipment suitable for practice
|
17 (71%)
|
13 (76%)
|
It is difficult to apply the ePrimaPrescribe platform if physical spaces are missing (eg consultation office with computer) - location of facilities
|
16 (67%)
|
9 (53%)
|
It is difficult to apply the ePrimaPrescribe platform if physical space is lacking (e.g. consulting room)- location of facilities
|
7 (29%)
|
9 (53%)
|
x2Pearson=162,15
Pr=0.130
Fisher’s exact=0.012
|