15. Interpretation

What to write

1. Nature of the association between the intervention(s) and the outcomes

2. Comparison of results with findings from other publications

3. Impact of the project on people and systems

4. Reasons for any differences between observed and anticipated outcomes, including the influence of context

5. Costs and strategic trade-offs, including opportunity costs

Examples

Example 1

1. After QI interventions, the percentage of patients attending four or more clinic visits significantly improved, and in 2012 we met our goal of 90% of patients attending four or more times a year. A systematic approach to scheduling processes, timely rescheduling of patients who missed appointments and monitoring of attendance resulted in a significant increase in the number of patients who met the CFF national recommendation of four or more visits per year.¹

2. Although the increase in the percentage of patients with greater than 25th centile for BMI/W-L from 80% to 82% might seem small, it represents a positive impact on a few more patients and provides more opportunities for improvement. Our data are in agreement with Johnson et al. (2003), who reported that frequent monitoring among other interventions made possible due to patients being seen more in clinic was associated with improved outcomes in CF.¹

3. We learned that families are eager to have input and be involved…participation in the(learning and leadership collaborative) resulted in a positive culture change at the ACH CF Care Center regarding the use of QI methods.¹

4. We noticed our clinic attendance started to improve before the(intervention) processes were fully implemented. We speculate this was due to the heightened awareness of our efforts by patients, families and our CF team.¹

5. Replication of these processes could be hindered by lack of personnel, lack of buy-in by the hospital administration and lack of patient/family involvement….barriers to attendance included rising fuel costs, transportation limitations, child care issues, missed workdays by caregivers and average low-income population.¹

Example 2

The direct involvement of patients and families…allowed us to address the social and medical barriers to adherence. Their input was invaluable since they live with the treatment burden that is a daily part of CF care…the in-clinic patient demonstration gave staff the ability to upgrade or replace equipment that was not functioning.²

We found that following a simple algorithm helped to maintain consistency in our program…the simplicity of this program makes it easily incorporated into routine CF clinic visits.²

Explanation

In the first example, Berlinski, et al¹ describe the implications of their improvement efforts by highlighting that they increased the proportion of CF patients receiving four clinic visits a year and achieved secondary improvements on a nutritional outcome and on the culture of their context. The authors also offer alternative explanations for outcomes, including factors which might have confounded the asserted relationship between intervention and outcome— namely that performance on the primary outcome began to improve well before implementation of the intervention. This provides insight into what the actual drivers of the outcome might have been, and can be very helpful to others seeking to replicate or modify the intervention. Finally, their comparison of their results to that of a similar study provides a basis for considerations of feasibility, sustainability, spread and replication of the intervention.

The second example, from Zanni, et al² found that the simplicity of their intervention could maximise ease of implementation, suggesting that costs and trade-offs are likely to be minimal for replication in similar contexts. Conversely, Berlinksi et al¹ cite barriers to replicating and sustaining their work, including staffing, leadership, population socioeconomic characteristics and informatics issues, each of which could present cost or trade-off considerations that leadership will need to consider to support implementation and sustainability. Additionally, both Berlinski et al and Zanni, et al observe that patient and family involvement in the planning and intervention process simultaneously improved the context and effectiveness of the intervention.

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References

1.

Berlinski A, Chambers MJ, Willis L, Homa K, Com G. Redesigning care to meet national recommendation of four or more yearly clinic visits in patients with cystic fibrosis. BMJ Quality & Safety. 2014;23(Suppl 1):i42-i49. doi:10.1136/bmjqs-2013-002345

2.

Zanni RL, Sembrano EU, Du DT, Marra B, Bantang R. The impact of re-education of airway clearance techniques (REACT) on adherence and pulmonary function in patients with cystic fibrosis. BMJ Quality & Safety. 2014;23(Suppl 1):i50-i55. doi:10.1136/bmjqs-2013-002352