# Implementation of a Quality Improvement and Clinical Decision Support Tool for Cancer Diagnosis in Primary Care: Process Evaluation

## TL;DR

A new tool called Future Health Today was tested in general practices to help diagnose cancer earlier, but its success varied due to time constraints and practice differences.

## Contribution

The study provides insights into the implementation challenges and variability in uptake of a cancer diagnosis support tool in primary care settings.

## Key findings

- Most practices only used the clinical decision support component of the tool due to its ease of use and acceptability.
- Low uptake of training and benchmarking components was reported, with time and resource constraints identified as barriers.
- Contextual factors like the pandemic and staff turnover affected practice participation and intervention effectiveness.

## Abstract

For patients with cancer, the pathway to diagnosis will most often begin in general practice. In the absence of strong diagnostic features or in patients with nonspecific symptoms, delays in diagnosis can occur. Initial presentations and routine blood tests are important in determining whether a patient requires further investigation. Quality improvement interventions, including auditing tools and clinical decision support (CDS), have been developed for use in general practice to support this diagnostic process. We conducted a process evaluation of a pragmatic, cluster-randomized trial that evaluated the effectiveness of a new technology, Future Health Today (FHT), implemented in general practice to assist with the appropriate follow-up of patients at risk of undiagnosed cancer.

This study aims to understand implementation gaps, explore differences between the general practices involved, provide context to the trial effectiveness outcomes, and understand the mechanisms behind the intervention successes and failures.

The trial intervention consisted of the FHT tool (with CDS, audit, recall, and quality improvement components), training and educational sessions, benchmarking reports, and ongoing practice support. The 21 general practices in the intervention arm of the trial were included in the process evaluation. Process data were collected using semistructured interviews, usability and educational session surveys, engagement with intervention components, and technical logs. The Medical Research Council’s Framework for Developing and Evaluating Complex Interventions was used to analyze and interpret the data.

The uptake of the supporting components of the intervention (training and education sessions, benchmarking reports) was low. Most practices only used the CDS component of the tool, facilitated by active delivery, with general practitioners reporting acceptability and ease of use. Complexity, time, and resources were reported as barriers to the use of the auditing tool. Access to a study coordinator and ongoing practice support facilitated the sustained involvement of practices in the trial, while contextual factors, such as the COVID-19 pandemic and staff turnover, impacted their level of participation. The relevance of the intervention varied between practices, with some practices reporting very low numbers of patients who were flagged for further investigation.

While some components of the intervention, such as the CDS tool, were considered to be acceptable and useful, this process evaluation highlighted barriers such as time and resources, practice differences, and considerations around the optimal amount of support needed when delivering the intervention. Addressing these in future studies may optimize the implementation process. Further work is needed to determine if a scaled-back approach, which meets the time and resource availability of a busy general practice, can effectively facilitate the implementation of CDS tools. Given the variation seen between practices, the use of the FHT cancer module may be better targeted to certain practices based on size, location, and patient demographics.