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Sykes M, Rosenberg-Yunger ZRS, Quigley M, Gupta L, Thomas O, Robinson L, Caulfield K, Ivers N, Alderson S. Exploring the content and delivery of feedback facilitation co-interventions: a systematic review. Implement Sci 2024; 19:37. [PMID: 38807219 PMCID: PMC11134935 DOI: 10.1186/s13012-024-01365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials. METHODS We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively. RESULTS We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time. CONCLUSIONS Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible. REVIEW REGISTRATION The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .
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Affiliation(s)
| | | | | | | | | | - Lisa Robinson
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Karen Caulfield
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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Gocuk SA, McKendrick AM, Downie LE. Point‐of‐care tools to support optometric care provision to people with age‐related macular degeneration: A randomised, placebo‐controlled trial. Ophthalmic Physiol Opt 2022; 42:814-827. [PMID: 35285531 PMCID: PMC9543223 DOI: 10.1111/opo.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
Abstract
Purpose Age‐related macular degeneration (AMD) is a leading cause of vision impairment. This randomised placebo‐controlled trial investigated whether point‐of‐care tools can improve optometrists' AMD knowledge and/or care provision. Methods Australian optometrists (n = 31) completed a demographics survey and theoretical AMD case study multiple‐choice questions (MCQs) to assess their confidence in AMD care provision and AMD knowledge. Participants were then randomly assigned to one of three point‐of‐care tools (online ‘Classification of Age‐related macular degeneration and Risk Assessment Tool’ (CARAT), paper CARAT, or ‘placebo’) to use when providing care to their subsequent 5–10 AMD patients. Participants self‐audited the compliance of their AMD care to best practice for these patients, and a similar number of consecutive patients seen prior to enrolment. Post‐intervention, participants retook the AMD knowledge MCQs and confidence survey. Results A total of 29 participants completed the study. At the study endpoint, clinical confidence relative to baseline improved with the paper CARAT, relative to placebo, for knowledge of AMD risk factors, asking patients about these factors and referring for medical retinal sub‐specialist care. There were no between‐group differences for the change in AMD knowledge scores. Considering record documentation for patients with any AMD severity, there were no significant between‐group differences for documenting patient risk factors, AMD severity, clinical examination techniques or management. In a sub‐analysis, the change from baseline in compliance for documenting discussions about patient smoking behaviours for early AMD patients was higher with use of the online CARAT relative to placebo (p = 0.04). For patients with intermediate AMD, the change from baseline in documenting the risk of progression to late AMD was greater among practitioners who used the paper CARAT, relative to placebo (p = 0.04). Conclusions This study demonstrates that point‐of‐care clinical tools can improve practitioner confidence and aspects of the documentation of AMD clinical care by optometrists as assessed by self‐audit.
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Affiliation(s)
- Sena A Gocuk
- Department of Optometry and Vision Sciences The University of Melbourne Parkville Victoria Australia
| | - Allison M McKendrick
- Department of Optometry and Vision Sciences The University of Melbourne Parkville Victoria Australia
| | - Laura E Downie
- Department of Optometry and Vision Sciences The University of Melbourne Parkville Victoria Australia
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Jull J, Köpke S, Smith M, Carley M, Finderup J, Rahn AC, Boland L, Dunn S, Dwyer AA, Kasper J, Kienlin SM, Légaré F, Lewis KB, Lyddiatt A, Rutherford C, Zhao J, Rader T, Graham ID, Stacey D. Decision coaching for people making healthcare decisions. Cochrane Database Syst Rev 2021; 11:CD013385. [PMID: 34749427 PMCID: PMC8575556 DOI: 10.1002/14651858.cd013385.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms. For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.
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Affiliation(s)
- Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Anne C Rahn
- Institute of Social Medicine and Epidemiology, Nursing Research Unit, University of Lubeck, Lubeck, Germany
| | - Laura Boland
- Integrated Knowledge Translation Research Network, The Ottawa Hospital Research Institute, Ottawa, Canada
- Western University, London, Canada
| | - Sandra Dunn
- BORN Ontario, CHEO Research Institute, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Andrew A Dwyer
- William F. Connell School of Nursing, Boston University, Chestnut Hill, Massachusetts, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jürgen Kasper
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Simone Maria Kienlin
- Faculty of Health Sciences, Department of Health and Caring Sciences, University of Tromsø, Tromsø, Norway
- The South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
| | - Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | | | - Claudia Rutherford
- School of Psychology, Quality of Life Office, University of Sydney, Camperdown, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Junqiang Zhao
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
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Falck L, Zoller M, Rosemann T, Martínez-González NA, Chmiel C. Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Systematic Review. JMIR Med Inform 2019; 7:e10879. [PMID: 31127717 PMCID: PMC6555125 DOI: 10.2196/10879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 03/20/2019] [Accepted: 04/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Long-term care for patients with chronic diseases poses a huge challenge in primary care. In particular, there is a deficit regarding monitoring and structured follow-up. Appropriate electronic medical records (EMRs) could help improving this but, so far, there are no evidence-based specifications concerning the indicators that should be monitored at regular intervals. Objective The aim was to identify and collect a set of evidence-based indicators that could be used for monitoring chronic conditions at regular intervals in primary care using EMRs. Methods We searched MEDLINE (Ovid), Embase (Elsevier), the Cochrane Library (Wiley), the reference lists of included studies and relevant reviews, and the content of clinical guidelines. We included primary studies and guidelines reporting about indicators that allow for the assessment of care and help monitor the status and process of disease for five chronic conditions, including type 2 diabetes mellitus, asthma, arterial hypertension, chronic heart failure, and osteoarthritis. Results The use of the term “monitoring” in terms of disease management and long-term care for patients with chronic diseases is not widely used in the literature. Nevertheless, we identified a substantial number of disease-specific indicators that can be used for routine monitoring of chronic diseases in primary care by means of EMRs. Conclusions To our knowledge, this is the first systematic review summarizing the existing scientific evidence on the standardized long-term monitoring of chronic diseases using EMRs. In a second step, our extensive set of indicators will serve as a generic template for evaluating their usability by means of an adapted Delphi procedure. In a third step, the indicators will be summarized into a user-friendly EMR layout.
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Affiliation(s)
- Leandra Falck
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Marco Zoller
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | | | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Shanbhag D, Graham ID, Harlos K, Haynes RB, Gabizon I, Connolly SJ, Van Spall HGC. Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review. BMJ Open 2018; 8:e017765. [PMID: 29511005 PMCID: PMC5855256 DOI: 10.1136/bmjopen-2017-017765] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. METHODS We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. RESULTS We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. CONCLUSION Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions.
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Affiliation(s)
- Deepti Shanbhag
- Bachelor of Health Sciences Program, McMaster University, Hamilton, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen Harlos
- Department of Business and Administration, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - R Brian Haynes
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Itzhak Gabizon
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Harriette Gillian Christine Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Deri Armstrong C, Taljaard M, Hogg W, Mark AE, Liddy C. Practice facilitation for improving cardiovascular care: secondary evaluation of a stepped wedge cluster randomized controlled trial using population-based administrative data. Trials 2016; 17:434. [PMID: 27596224 PMCID: PMC5011906 DOI: 10.1186/s13063-016-1547-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Practice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients (N = 5292). Here, we used population-based administrative data to examine IDOCC's effect on CVD-related hospitalizations. METHODS IDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC's effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness. RESULTS Our sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses. CONCLUSIONS Clinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period. TRIAL REGISTRATION ClinicalTrials.gov NCT00574808 , registered on 14 December 2007.
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Affiliation(s)
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Amy E Mark
- Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Van Hoof TJ, Harrison LG, Miller NE, Pappas MS, Fischer MA. Characteristics of Academic Detailing: Results of a Literature Review. AMERICAN HEALTH & DRUG BENEFITS 2015; 8:414-422. [PMID: 26702333 PMCID: PMC4684632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/10/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Academic detailing is an evidence-based strategy to improve patient care. Efforts to understand the intervention and to use it strategically require an understanding of its important characteristics. A recent systematic review and a subsequent reporting framework call for more accurate and complete reporting of continuing medical education interventions. OBJECTIVES Building on a previously published systematic review of 69 studies, we sought to determine how an expanded set of 106 academic detailing studies, including many recently published articles, fared with respect to reporting of important data about this intervention. METHODS We conducted a search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (clinical) database, and Scopus, from which we identified 38 additional randomized controlled trials published from August 2007 through March 2013. Including the original 69 studies, we abstracted 106 available English-language studies and quantitatively analyzed information about 4 important characteristics of academic detailing: content of visits, clinicians being visited, communication process underlying visits, and outreach workers making visits. RESULTS We found considerable variation (36.5%-100%) in the extent of reporting intervention characteristics, especially about the communication process underlying visits and the outreach workers making visits. The best overall documentation of intervention characteristics of any single study was 68%. Results also demonstrate wide variation in the approach to academic detailing. CONCLUSIONS This study demonstrates the need for a standardized approach to collecting and reporting data about academic detailing interventions. Our findings also highlight opportunities for using academic detailing more effectively in research and quality-improvement efforts.
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Affiliation(s)
- Thomas J Van Hoof
- Associate Professor, University of Connecticut School of Nursing, Storrs, CT, and Associate Professor, Department of Community Medicine and Health Care, University of Connecticut School of Medicine, Farmington, CT
| | - Lisa G Harrison
- PhD candidate, University of Connecticut School of Nursing, Storrs, CT
| | | | - Maryanne S Pappas
- Nurse Practitioner, Division of Neuroscience, Hartford Hospital, Hartford, CT, and a PhD candidate, University of Connecticut School of Nursing, Storrs, CT
| | - Michael A Fischer
- Director, National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Associate Professor, Harvard Medical School, Boston, MA
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Liddy C, Hogg W, Singh J, Taljaard M, Russell G, Deri Armstrong C, Akbari A, Dahrouge S, Grimshaw JM. A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care. Implement Sci 2015; 10:150. [PMID: 26510577 PMCID: PMC4625868 DOI: 10.1186/s13012-015-0341-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/19/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery. METHODS A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention. RESULTS Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively. CONCLUSIONS IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT00574808.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. .,Bruyère Research Institute, 43 Bruyère St, Annex E, Room 106, Ottawa, Ontario, K1N 5C8, Canada.
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Jatinderpreet Singh
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. .,Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada.
| | - Grant Russell
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria, Australia.
| | | | - Ayub Akbari
- The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Simone Dahrouge
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. .,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Nouwens E, van Lieshout J, Wensing M. Determinants of impact of a practice accreditation program in primary care: a qualitative study. BMC FAMILY PRACTICE 2015; 16:78. [PMID: 26137870 PMCID: PMC4490740 DOI: 10.1186/s12875-015-0294-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 06/12/2015] [Indexed: 11/16/2022]
Abstract
Background Practice accreditation is a widely used method to assess and improve the quality of healthcare services. In the Netherlands, a practice accreditation program was implemented in primary medical care. We aimed to identify determinants of impact of a practice accreditation program, building on the experiences of primary care professionals who had participated in this program. Methods An interview study was done to document the experiences of 33 participating primary care professionals and used to identify determinants of outcomes. The Consolidated Framework for Implementation Research (CFIR) was used as framework for the qualitative analysis. Results After analyzing 23 interviews saturation was reached. The practice accreditation program is based on structured quality improvement, but only some of its elements were identified as determinants of impact. Factors that were perceived to facilitate implementation of the program were: designating one person responsible for the program, ensuring clear lines of communication within the whole practice team and having affinity with or stimulate enthusiasm for improving quality of care. Contextual factors such as participation in a care group and being connected to the GP educational institute were important for actual change. The accreditation program was perceived to have positive effects on team climate and commitment to quality of care in the practice team. The perception was that patient care was not directly influenced by the accreditation program. Receiving a certificate for completing the accreditation program seemed to have little added value to participants. Conclusions Practice accreditation may have positive outcomes on quality of care, but not all planned elements may contribute to its outcomes. Both factors in the accreditation process and in the context were perceived as determinants of quality improvement. The challenge is to build on facilitating factors, while reducing the elements of accreditation that do not contribute to its impact. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0294-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elvira Nouwens
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, P.O. Box 9101 , 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.
| | - Jan van Lieshout
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, P.O. Box 9101 , 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.
| | - Michel Wensing
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, P.O. Box 9101 , 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.
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Groot-Jensen S, Kiessling A, Zethraeus N, Björnstedt-Bennermo M, Henriksson P. Cost-effectiveness of case-based training for primary care physicians in evidence-based medicine of patients with coronary heart disease. Eur J Prev Cardiol 2015; 23:420-7. [DOI: 10.1177/2047487315583798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/02/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Susanne Groot-Jensen
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden
| | - Anna Kiessling
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden
| | | | - Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden
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Nouwens E, van Lieshout J, Bouma M, Braspenning J, Wensing M. Effectiveness of improvement plans in primary care practice accreditation: a clustered randomized trial. PLoS One 2014; 9:e114045. [PMID: 25463149 PMCID: PMC4252098 DOI: 10.1371/journal.pone.0114045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 08/11/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Accreditation of healthcare organizations is a widely used method to assess and improve quality of healthcare. Our aim was to determine the effectiveness of improvement plans in practice accreditation of primary care practices, focusing on cardiovascular risk management (CVRM). METHOD A two-arm cluster randomized controlled trial with a block design was conducted with measurements at baseline and follow-up. Primary care practices allocated to the intervention group (n = 22) were instructed to focus improvement plans during the intervention period on CVRM, while practices in the control group (n = 23) could focus on any domain except on CVRM and diabetes mellitus. Primary outcomes were systolic blood pressure <140 mmHg, LDL cholesterol <2.5 mmol/l and prescription of antiplatelet drugs. Secondary outcomes were 17 indicators of CVRM and physician's perceived goal attainment for the chosen improvement project. RESULTS No effect was found on the primary outcomes. Blood pressure targets were reached in 39.8% of patients in the intervention and 38.7% of patients in the control group; cholesterol target levels were reached in 44.5% and 49.0% respectively; antiplatelet drugs were prescribed in 82.7% in both groups. Six secondary outcomes improved: smoking status, exercise control, diet control, registration of alcohol intake, measurement of waist circumference, and fasting glucose. Participants' perceived goal attainment was high in both arms: mean scores of 7.9 and 8.2 on the 10-point scale. CONCLUSIONS The focus of improvement plans on CVRM in the practice accreditation program led to some improvements of CVRM, but not on the primary outcomes. ClinicalTrials.gov NCT00791362.
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Affiliation(s)
- Elvira Nouwens
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
- * E-mail:
| | - Jan van Lieshout
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Margriet Bouma
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Jozé Braspenning
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Michel Wensing
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
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Unverzagt S, Peinemann F, Oemler M, Braun K, Klement A. Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care. PLoS One 2014; 9:e110619. [PMID: 25343450 PMCID: PMC4208765 DOI: 10.1371/journal.pone.0110619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/15/2014] [Indexed: 11/18/2022] Open
Abstract
This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Frank Peinemann
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Matthias Oemler
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Kristin Braun
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Andreas Klement
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
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Van Hoof TJ, Miller NE. Consequences of a lack of standardization of continuing education terminology: the case of practice facilitation and educational outreach. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2014; 34:83-86. [PMID: 24648367 DOI: 10.1002/chp.21212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Systematic reviews published in the quality improvement and continuing education literature have noted that the lack of standardized terminology for categorizing and describing various interventions in published studies is a major obstacle to drawing conclusions about their effectiveness. A case in point is practice facilitation and educational outreach. Although they are 2 long-standing interventions with some common characteristics, researchers studying 1 intervention may be unfamiliar with the other given the relatively separate literatures that have developed around both sets of terms. A comparison of articles included in recent systematic reviews of practice facilitation and educational outreach revealed a small but significant overlap of articles, journals, key words, and noncorresponding authors, but no overlap of corresponding authors. Based on these findings, the authors join the call for the creation of an intervention taxonomy and its application to these and other continuing education interventions.
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Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial. Implement Sci 2012; 7:94. [PMID: 23035760 PMCID: PMC3533965 DOI: 10.1186/1748-5908-7-94] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/28/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases. METHODS/DESIGN We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation. DISCUSSION It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices.
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Asmar R, Achouba A, Brunel P, El Feghali R, Denolle T, Vaisse B. A specific training on hypertension guidelines improves blood pressure control by more than 10% in hypertensive patients: the VALNORM study. ACTA ACUST UNITED AC 2012; 1:278-85. [PMID: 20409859 DOI: 10.1016/j.jash.2007.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 04/18/2007] [Accepted: 04/18/2007] [Indexed: 11/15/2022]
Abstract
VALNORM was designed to assess the impact on blood pressure (BP) control of a specific training in new European Society of Hypertension-International Society of Hypertension (ESH-ISH) guidelines for hypertension management. It was an 8-week prospective, randomized, open, blinded end points design study. General practitioners (GPs) located in France were randomized in two groups: group 1 (G1) without training to the guidelines and free attitude for the prescription whereas group 2 (G2) received a specific training in ESH guidelines. The primary efficacy criteria was strict BP control at week 8 (systolic BP/diastolic BP [SBP/DBP] <140/90 mm Hg and/or SBP/DBP <130/80 mm Hg if diabetes or renal insufficiency). All physicians used the same treatment (valsartan 80 or 160 mg once daily alone or in fixed combination with hydrochlorothiazide 12.5 or 25 mg once daily). BP was measured in the GPs' office with an electronic device. The groups GPs included 4,436 patients with essential uncontrolled hypertension (G1: 595 physicians, 2,308 patients; G2: 502 physicians, 2,128 patients). Patients' main characteristics were: age = 61 +/- 13 years, 52% female, BP = 160 +/- 13/92 +/- 9 mm Hg. No difference was observed between the two groups. The primary efficacy criteria showed in G2: 47.8% of BP control vs. G1: 44.7%, P = .005. Subgroup analysis according to age, body mass index (BMI), previous diabetes, and antihypertensive treatment showed that higher efficacy in G2 was more significant in these high-risk subgroups: age >60 years (G1: n = 1,150, G2: n = 1,035), BMI >/=25 kg/m(2) (G1: n = 1540, G2: n = 1430), diabetes (G1: n = 267, G2: n = 290), no previous antihypertensive treatment (G1: n = 1,111, G2: n = 1,005). The percentage of patients with controlled BP in each subgroup was: diabetes: G1 11.2% vs. G2 17.9% (P = .001), age >60 years: G1 40.3% vs. G2 43.7% (P = .022), BMI >/=25 kg/m(2): G1 43.2% vs. G2 45% (P = .165), untreated: G1 48.2% vs. G2 52.4% (P = .005). Specific training on the guidelines showed a positive impact on BP control, highly significant in patients at high cardiovascular risk such as diabetic hypertensive patients.
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Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: a systematic review. Health Policy 2012; 107:168-83. [PMID: 22940062 DOI: 10.1016/j.healthpol.2012.08.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 07/17/2012] [Accepted: 08/07/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE AND SETTING This review aimed to evaluate the effectiveness of strategies to implement clinical guidelines for chronic disease management in primary care in EU Member States. METHODS We conducted a systematic review of interventional studies assessing the implementation of clinical guidelines. We searched five databases (EMBASE, MEDLINE, CENTRAL, Eppi-Centre and Clinicaltrials.gov) following a strict Cochrane methodology. We included studies focusing on the management of chronic diseases in adults in primary care. RESULTS A total of 21 studies were found. The implementation strategy was fully effective in only four (19%), partially effective in eight (38%), and not effective in nine (43%). The probability that an intervention would be effective was only slightly higher with multifaceted strategies, compared to single interventions. However, effect size varied across studies; therefore it was not possible to determine the most successful strategy. Only eight studies evaluated the impact on patients' health and only two of those showed significant improvement, while in five there was an improvement in the process of care which did not translate into an improvement in health outcomes. Only four studies reported any data on the cost of the implementation but none undertook a cost-effectiveness analysis. Only one study presented data on the barriers to the implementation of guidelines, noting a lack of awareness and agreement about clinical guidelines. CONCLUSION Our results reveal that there are only a few rigorous studies which assess the effectiveness of a strategy to implement clinical guidelines in Europe. Moreover, the results are not consistent in showing which strategy is the most appropriate to facilitate their implementation. Therefore, further research is needed to develop more rigorous studies to evaluate health outcomes associated with the implementation of clinical guidelines; to assess the cost-effectiveness of implementing clinical guidelines; and to investigate the perspective of service users and health service staff.
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Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012:CD000259. [PMID: 22696318 DOI: 10.1002/14651858.cd000259.pub3] [Citation(s) in RCA: 1351] [Impact Index Per Article: 112.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact. OBJECTIVES To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011). SELECTION CRITERIA Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included. DATA COLLECTION AND ANALYSIS All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors. MAIN RESULTS We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention. AUTHORS' CONCLUSIONS Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.
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Affiliation(s)
- Noah Ivers
- Department of Family Medicine, Women’s College Hospital, Toronto, Canada. 2Norwegian Knowledge Centre for the Health Services,Oslo,
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Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74. [PMID: 22230833 PMCID: PMC3262473 DOI: 10.1370/afm.1312] [Citation(s) in RCA: 344] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study was a systematic review with a quantitative synthesis of the literature examining the overall effect size of practice facilitation and possible moderating factors. The primary outcome was the change in evidence-based practice behavior calculated as a standardized mean difference. METHODS In this systematic review, we searched 4 electronic databases and the reference lists of published literature reviews to find practice facilitation studies that identified evidence-based guideline implementation within primary care practices as the outcome. We included randomized and nonrandomized controlled trials and prospective cohort studies published from 1966 to December 2010 in English language only peer-reviewed journals. Reviews of each study were conducted and assessed for quality; data were abstracted, and standardized mean difference estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Publication bias, influence, subgroup, and meta-regression analyses were also conducted. RESULTS Twenty-three studies contributed to the analysis for a total of 1,398 participating practices: 697 practice facilitation intervention and 701 control group practices. The degree of variability between studies was consistent with what would be expected to occur by chance alone (I2 = 20%). An overall effect size of 0.56 (95% CI, 0.43-0.68) favored practice facilitation (z = 8.76; P <.001), and publication bias was evident. Primary care practices are 2.76 (95% CI, 2.18-3.43) times more likely to adopt evidence-based guidelines through practice facilitation. Meta-regression analysis indicated that tailoring (P = .05), the intensity of the intervention (P = .03), and the number of intervention practices per facilitator (P = .004) modified evidence-based guideline adoption. CONCLUSION Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.
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Affiliation(s)
- N Bruce Baskerville
- Propel Centre for Population Health Impact, University of Waterloo, Ontario, Canada.
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Liddy C, Hogg W, Russell G, Wells G, Armstrong CD, Akbari A, Dahrouge S, Taljaard M, Mayo-Bruinsma L, Singh J, Cornett A. Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care. Implement Sci 2011; 6:110. [PMID: 21952084 PMCID: PMC3197547 DOI: 10.1186/1748-5908-6-110] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 09/27/2011] [Indexed: 01/12/2023] Open
Abstract
Background There is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation. Methods The IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation. Discussion This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada. Trial Registration ClinicalTrials.gov: NCT00574808
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Affiliation(s)
- Clare Liddy
- C. T. Lamont Primary Health Care Research Centre, Elisabeth Bruyère Research Institute, Ottawa, Ontario, Canada.
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Welschen LMC, Bot SDM, Dekker JM, Timmermans DRM, van der Weijden T, Nijpels G. The @RISK Study: Risk communication for patients with type 2 diabetes: design of a randomised controlled trial. BMC Public Health 2010; 10:457. [PMID: 20687924 PMCID: PMC2922111 DOI: 10.1186/1471-2458-10-457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 08/05/2010] [Indexed: 11/23/2022] Open
Abstract
Background Patients with type 2 diabetes mellitus (T2DM) have an increased risk to develop severe diabetes related complications, especially cardiovascular disease (CVD). The risk to develop CVD can be estimated by means of risk formulas. However, patients have difficulties to understand the outcomes of these formulas. As a result, they may not recognize the importance of changing lifestyle and taking medication in time. Therefore, it is important to develop risk communication methods, that will improve the patients' understanding of risks associated with having diabetes, which enables them to make informed choices about their diabetes care. The aim of this study is to investigate the effects of an intervention focussed on the communication of the absolute 10-year risk to develop CVD on risk perception, attitude and intention to change lifestyle behaviour in patients with T2DM. The conceptual framework of the intervention is based on the Theory of Planned Behaviour and the Self-regulation Theory. Methods A randomised controlled trial will be performed in the Diabetes Care System West-Friesland (DCS), a managed care system. Newly referred T2DM patients of the DCS, younger than 75 years will be eligible for the study. The intervention group will be exposed to risk communication on CVD, on top of standard managed care of the DCS. This intervention consists of a simple explanation on the causes and consequences of CVD, and possibilities for prevention. The probabilities of CVD in 10 year will be explained in natural frequencies and visualised by a population diagram. The control group will receive standard managed care. The primary outcome is appropriateness of risk perception. Secondary outcomes are attitude and intention to change lifestyle behaviour and illness perception. Differences between baseline and follow-up (2 and 12 weeks) between groups will be analysed according to the intention-to-treat principle. The study was powered on 120 patients in each group. Discussion This innovative risk communication method based on two behavioural theories might improve patient's appropriateness of risk perception and attitude concerning lifestyle change. With a better understanding of their CVD risk, patients will be able to make informed choices concerning diabetes care. Trail registration The trial is registered as NTR1556 in the Dutch Trial Register.
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Affiliation(s)
- Laura M C Welschen
- Department of General Practice, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.
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The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs. Can J Cardiol 2010; 26:185-202. [PMID: 20386768 DOI: 10.1016/s0828-282x(10)70367-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.
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Gardner B, Whittington C, McAteer J, Eccles MP, Michie S. Using theory to synthesise evidence from behaviour change interventions: the example of audit and feedback. Soc Sci Med 2010; 70:1618-25. [PMID: 20207464 DOI: 10.1016/j.socscimed.2010.01.039] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 12/02/2009] [Accepted: 01/28/2010] [Indexed: 11/19/2022]
Abstract
Evidence syntheses are used to inform health care policy and practice. Behaviour change theories offer frameworks for categorising and evaluating interventions and identifying likely mechanisms through which effects are achieved. Yet systematic reviews rarely explicitly classify intervention components using theory, which may result in evidence syntheses and health care practice recommendations that are less than optimal. This paper outlines a method for applying theory to evidence syntheses of behaviour change interventions. We illustrate this method with an analysis of 'audit and feedback' interventions, based on data from a Cochrane review. Our analysis is based on Control Theory, which suggests that behaviour change is most likely if feedback is accompanied by comparison with a behavioural target and by action plans, and we coded interventions for these three techniques. Multivariate meta-regression was performed on 85 comparisons from 61 studies. However, few interventions incorporated targets or action plans, and so meta-regression models were likely to be underfitted due to insufficient power. The utility of our approach could not be tested via our analysis because of the limited nature of the audit and feedback interventions. However, we show that conceptualising and categorising interventions using behaviour change theory can reveal the theoretical coherence of interventions and so point towards improvements in intervention design, evaluation and synthesis. The results demonstrate that a theory-based approach to evidence synthesis is feasible, and can prove beneficial in understanding intervention design, even where there is insufficient empirical evidence to reliably synthesise effects of specific intervention components.
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Affiliation(s)
- Benjamin Gardner
- Centre for Outcomes Research and Effectiveness, University College London, 1-19 Torrington Place, London WC1E 7HB, UK.
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Abstract
Evidence-based practice is a goal for all institutions and often an accreditation requirement. However, moving forward to "just do it" poses a problem for nurses in most patient care units. In spite of increased focus on evidence-based practice initiatives, creation of a systematic approach that effectively integrates the evidence for our practice into the minute-by-minute activities of patient care is still needed. In this article, the steps for accomplishing evidence-based practice in the clinical area are described, beginning with establishing a system to identify, evaluate, and prioritize clinical questions and existing research. Although conducting new, unit-based nursing research may seem a distant goal, beginning with initiatives to increase the use of existing evidence in practice is a first step to this goal, one that contributes to professional development and improved patient outcomes.
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Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature. BMC Health Serv Res 2008; 8:60. [PMID: 18366711 PMCID: PMC2294118 DOI: 10.1186/1472-6963-8-60] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 03/20/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms. METHODS We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers. RESULTS 11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions. CONCLUSION Our review provides preliminary evidence that physicians' knowledge of global CHD risk scores may translate into modestly increased prescribing of cardiovascular drugs and modest short-term reductions in CHD risk factors without clinical harm. Whether these results are replicable, and translate across other practice settings or into improved long-term CHD outcomes remains to be seen.
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El Fakiri F, Hoes AW, Uitewaal PJM, Frenken RAA, Bruijnzeels MA. Process evaluation of an intensified preventive intervention to reduce cardiovascular risk in general practices in deprived neighbourhoods. Eur J Cardiovasc Nurs 2008; 7:296-302. [PMID: 18296125 DOI: 10.1016/j.ejcnurse.2008.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2006] [Revised: 10/07/2007] [Accepted: 01/06/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND A RCT, conducted to examine the effectiveness of a structured collaboration in general practice to provide intensified preventive care in patients at high cardiovascular risk yielded no effect in the total group but differences across healthcare centres and ethnic groups become apparent. We conducted a process evaluation to explain these differences. METHODS We assessed the reach of the target group and whether key intervention components (individual educational sessions, structured team meetings, and risk assessments) were performed as planned (maximum score for protocol completion is 11). RESULTS The reach was initially 91%, but only a minority of patients completed the intervention activities as planned. The average score of the number of intervention components was low (5.66 out of 11 (sd 2.8)) and varied between centres (4.84 to 7.40) and ethnic groups (4.89 to 7.38), with team meetings as the least implemented activity conform plan. CONCLUSION This study indicates that adding a practice nurse and a peer health educator to the general practice did not seem to result in the desired collaboration between the healthcare personnel. Further research is needed to investigate the reasons behind the low participation rate of the patients in the intervention.
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Affiliation(s)
- Fatima El Fakiri
- Department of Health Policy and Management, Erasmus Medical Centre Rotterdam, Netherlands.
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O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2007; 2007:CD000409. [PMID: 17943742 PMCID: PMC7032679 DOI: 10.1002/14651858.cd000409.pub2] [Citation(s) in RCA: 512] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting. OBJECTIVES To assess the effects of EOVs on health professional practice or patient outcomes. SEARCH STRATEGY For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL. SELECTION CRITERIA Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention. MAIN RESULTS We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed. AUTHORS' CONCLUSIONS EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.
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Affiliation(s)
- M A O'Brien
- Juravinski Cancer Centre, Supportive Cancer Care Research Unit, 699 Concession Street, Hamilton, Ontario, Canada, L8V 5C2. maryann.o'
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Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006:CD000259. [PMID: 16625533 DOI: 10.1002/14651858.cd000259.pub2] [Citation(s) in RCA: 496] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective. OBJECTIVES To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004. SELECTION CRITERIA Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality. MAIN RESULTS Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies. AUTHORS' CONCLUSIONS Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.
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Affiliation(s)
- G Jamtvedt
- Norwegian Health Services Reserch Centre, Postboks 7004 St. Olavsplass, 0031 Oslo, Norway.
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McQuigg M, Brown J, Broom J, Laws RA, Reckless JPD, Noble PA, Kumar S, McCombie EL, Lean MEJ, Lyons GF, Frost GS, Quinn MF, Barth JH, Haynes SM, Finer N, Ross HM, Hole DJ. Empowering primary care to tackle the obesity epidemic: the Counterweight Programme. Eur J Clin Nutr 2005; 59 Suppl 1:S93-100; discussion S101. [PMID: 16052202 DOI: 10.1038/sj.ejcn.1602180] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To improve the management of obese adults (18-75 y) in primary care. DESIGN Cohort study. SETTINGS UK primary care. SUBJECTS Obese patients (body mass index > or =30 kg/m(2)) or BMI> or =28 kg/m(2) with obesity-related comorbidities in 80 general practices. INTERVENTION The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. MAIN OUTCOME MEASURES Proportion of practices trained and recruiting patients, and weight change at 12 months. RESULTS By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as 'completers' in that they attended the requisite number of appointments in 3, 6 and 12 months. 'Completers' achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months. CONCLUSION The Counterweight programme provides a promising model to improve the management of obesity in primary care.
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Affiliation(s)
- M McQuigg
- Diabetes Centre, Royal United Hospital, Bath, UK
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Frijling B, Hulscher MEJL, van Leest LATM, Braspenning JCC, van den Hoogen H, Drenthen AJM, Grol RPTM. Multifaceted support to improve preventive cardiovascular care: a nationwide, controlled trial in general practice. Br J Gen Pract 2003; 53:934-41. [PMID: 14960217 PMCID: PMC1314746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Multifaceted interventions improve the quality of preventive cardiovascular care in general practice when applied in small-scale research trials. AIM To test the transferability of observations from research trials on preventive cardiovascular care to a real-world situation and, therefore, evaluate the effectiveness of a nationwide project with a large number of practices. The intervention comprised a combination of conferences, dissemination of manuals, and support from trained non-physicians during outreach visits. DESIGN OF STUDY A controlled before-and-after trial with two arms: multifaceted support versus no special attention. Analysis after 2 years. SETTING 617 general practices in The Netherlands. METHOD Outcomes measures were the compliance rates for 15 indicators. Structure-of-care indicators included the use of reminders, specific computer files, written protocols, and special clinics. Process-of-care indicators included the assessment of modifiable risk factors and use of a minimal contact intervention (MCI) for smoking cessation. Compliance of general practitioners (GPs) was assessed using self-administered questionnaires. RESULTS The intervention group improved on all eight of the structure-of-care indicators when compared to the control group. A positive effect was also found on the extent to which the GPs measured blood pressure in 60-year-old patients and on the use of an MCI for smoking cessation. No effect was found on the completeness of the risk-factor profiles that the GPs assessed in specific groups of high-risk patients. CONCLUSION The nationwide intervention appeared to improve certain aspects of preventive cardiovascular care. Nevertheless, the National Association of GPs decided to stop the project. This decision was made within the context of discussions about the heavy workloads and insufficient incomes being experienced by GPs.
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