BACKGROUND: The underuse or overuse of knowledge products leads to waste in healthcare, and primary care is no exception.
OBJECTIVE: We aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.
METHODS: We performed a systematic review of systematic reviews (SR) using the Cochrane systematic approach to include eligible SR. The inclusion criteria were: any primary care contexts; healthcare professionals and patients; any EPOC implementation strategies of specified knowledge products; any comparator; and any implementation outcomes based on the Proctor framework. We searched the Medline, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019, without any restriction. We searched the references of the included SR. Pairs of reviewers independently performed selection, data extraction and methodological quality assessment with AMSTAR 2. Data extraction was informed by EPOC taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results using a narrative synthesis.
RESULTS: Of the 11,101 records identified, 81 SR were included. Forty-seven SR involved healthcare professionals alone. Fifteen SR were of high or moderate methodological quality. Most of them addressed one type of knowledge product (56/81), common clinical practice guidelines (26/56) or management, and behavioural or pharmacological health interventions (24/56). Mixed strategies were used for implementation (67/81), predominantly educational-based (meetings in 60/81, materials distribution in 59/81, and academic detailing in 45/81), reminder (53/81) and audit and feedback (40/81) strategies. Education meetings (P=.13) and academic detailing (P=.11) seem to be more used when the population is composed of Healthcare professionals alone. The improvement of the adoption of knowledge products was the most commonly measured outcome (72/81). The evidence level was reported in 10/81 SR on 62 outcomes (including 48 improvement of adoption), of which 16 outcomes were of moderate or high level.
CONCLUSIONS: Clinical practice guidelines and management, behavioural or pharmacological health interventions are the most commonly implemented knowledge products through the mixed use of educational, reminders and audit and feedback strategies. There is need for a strong methodology for the SR of RCTs to explore their effectiveness and the whole cascade of implementation outcomes.
CLINICALTRIAL: Not applicable.
CONTEXT: Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements.
OBJECTIVES: The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.
DATA SOURCES AND REVIEW METHODS: We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006 of MEDLINE(®), and November 15, 2006 for CINAHL(®), Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider.
RESULTS: We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic reviews evaluating care coordination interventions, either fully or as a part of the review, met inclusion criteria. From these, we identified 20 different coordination interventions (e.g., multidisciplinary teams, case management, disease management) covering 12 clinical populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen's behavioral framework, Donabedian's structure-process-outcome framework, Nadler/Tushman and others' Organizational design framework with Wagner's Chronic Care Model provided as an example of such design, and Gittell's Relational coordination framework) with potential applicability to studying care coordination by assessing baseline characteristics of the environment, specific coordination mechanism alternatives, and outcomes. The strongest evidence shows benefit of care coordination interventions for patients who have congestive heart failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence about key intervention components is lacking.
CONCLUSIONS: Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problem, though more conceptual, empirical and experimental research is required to explore this hypothesis.
The underuse or overuse of knowledge products leads to waste in healthcare, and primary care is no exception.
OBJECTIVE:
We aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.
METHODS:
We performed a systematic review of systematic reviews (SR) using the Cochrane systematic approach to include eligible SR. The inclusion criteria were: any primary care contexts; healthcare professionals and patients; any EPOC implementation strategies of specified knowledge products; any comparator; and any implementation outcomes based on the Proctor framework. We searched the Medline, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019, without any restriction. We searched the references of the included SR. Pairs of reviewers independently performed selection, data extraction and methodological quality assessment with AMSTAR 2. Data extraction was informed by EPOC taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results using a narrative synthesis.
RESULTS:
Of the 11,101 records identified, 81 SR were included. Forty-seven SR involved healthcare professionals alone. Fifteen SR were of high or moderate methodological quality. Most of them addressed one type of knowledge product (56/81), common clinical practice guidelines (26/56) or management, and behavioural or pharmacological health interventions (24/56). Mixed strategies were used for implementation (67/81), predominantly educational-based (meetings in 60/81, materials distribution in 59/81, and academic detailing in 45/81), reminder (53/81) and audit and feedback (40/81) strategies. Education meetings (P=.13) and academic detailing (P=.11) seem to be more used when the population is composed of Healthcare professionals alone. The improvement of the adoption of knowledge products was the most commonly measured outcome (72/81). The evidence level was reported in 10/81 SR on 62 outcomes (including 48 improvement of adoption), of which 16 outcomes were of moderate or high level.
CONCLUSIONS:
Clinical practice guidelines and management, behavioural or pharmacological health interventions are the most commonly implemented knowledge products through the mixed use of educational, reminders and audit and feedback strategies. There is need for a strong methodology for the SR of RCTs to explore their effectiveness and the whole cascade of implementation outcomes.
