OBJECTIVES: To assess the comparative effectiveness of interventions for improving antibiotic use for acute respiratory tract infections (RTIs) in adults and children.
DATA SOURCES: Electronic databases (MEDLINE(®) from 1990 and the Cochrane Library databases from 2005 to February 2015), reference lists of included systematic reviews, and Scientific Information Packets from point-of-care test manufacturers and experts.
REVIEW METHODS: Using predefined criteria, we selected studies of any intervention designed to improve antibiotic use for acute RTIs for which antibiotics are not indicated. Interventions were organized into education, communication, clinical, system-level, and multifaceted categories. We identified interventions that had evidence of reducing resistance to antibiotics, improving appropriate prescribing (i.e., concordant with guidelines), or decreasing overall prescribing of antibiotics for acute RTIs and not causing adverse consequences such as medical complications or patient dissatisfaction. The quality of included studies was rated and the strength of the evidence was assessed. Clinical and methodological heterogeneity limited quantitative analysis.
RESULTS: Although reduction in antibiotic resistance is a major goal of these interventions, there were too few studies to assess this outcome. The few studies that attempted to assess appropriate prescribing had important limitations and lack of consistency in outcome definition and ascertainment methods across studies. Therefore, reduction in overall prescribing was the only commonly reported benefit across interventions. Actual use of antibiotics was also reported in too few studies to assess separately from prescribing. No intervention had high-strength evidence for any outcome. The best evidence, from an evidence base of 133 studies, including 88 randomized controlled trials, was for four interventions with moderate-strength evidence of improved or reduced antibiotic prescribing compared with usual care that also had low-strength evidence of not causing adverse consequences. These were clinic-based parent education (21% overall prescribing reduction; similar return visits); public patient education campaigns combined with clinician education (improved appropriate prescribing; 7% reduction in overall prescribing; similar complications and satisfaction); procalcitonin for adults (12% to 72% overall prescribing reduction; similar continuing symptoms, limited activity, missing work, adverse events or lack of efficacy, treatment failure, hospitalizations, and mortality); and electronic decision support systems (improved appropriate prescribing and 5% to 9% reduction in overall prescribing; similar complications and health care use). Additionally, public parent education campaigns had low-strength evidence of reducing overall prescribing, not increasing diagnosis of complications, and decreasing subsequent visits. Other interventions had evidence of improved or reduced prescribing, but evidence on adverse consequences was lacking (streptococcal antigen testing, rapid multiviral testing in adults), insufficient (clinician and patient education plus audit and feedback plus academic detailing), or mixed (delayed prescribing, C-reactive protein [CRP] testing, clinician communication training, communication training plus CRP testing). Interventions with evidence of no impact on antibiotic prescribing were clinic-based education for parents of children 24 months or younger with acute otitis media, point-of-care testing for influenza or tympanometry in children, and clinician education combined with audit and feedback. Furthermore, limited evidence suggested that using adult procalcitonin algorithms in children is not effective and results in increased antibiotic prescribing.
CONCLUSIONS: The best evidence supports the use of specific education interventions for patients/parents and clinicians, procalcitonin in adults, and electronic decision support to reduce overall antibiotic prescribing (and in some cases improve appropriate prescribing) for acute RTIs without causing adverse consequences, although the reduction in prescribing varied widely. Other interventions also reduced prescribing, but evidence on adverse consequences was lacking, insufficient, or mixed. Future studies should use a complex intervention framework and better evaluate measures of appropriate prescribing, adverse consequences such as hospitalization, sustainability, resource use, and the impact of potential effect modifiers. PROSPERO number: CRD42014010094.
OBJECTIVES: There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are generally unclear. We conducted a systematic review to identify effective methods of implementing clinical research findings and clinical guidelines to change physician practice patterns, in surgical and general practice. STUDY DESIGN: Systematic review of reviews. METHODS: We searched electronic databases (MEDLINE, EMBASE, and PubMed) for systematic reviews published in English that evaluated the effectiveness of different implementation methods. Two reviewers independently assessed eligibility for inclusion and methodological quality, and extracted relevant data. RESULTS: Fourteen reviews covering a wide range of interventions were identified. The intervention methods used include: audit and feedback, computerized decision support systems, continuing medical education, financial incentives, local opinion leaders, marketing, passive dissemination of information, patient-mediated interventions, reminders, and multifaceted interventions. Active approaches, such as academic detailing, led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active educational methods and multifaceted interventions. CONCLUSIONS: Active forms of continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice. Additionally, active approaches to changing physician performance were shown to improve practice to a greater extent than traditional passive methods. Further primary research is necessary to evaluate the effectiveness of these methods in a surgical setting.
CONTEXT: Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions.
EVIDENCE ACQUISITION: Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews.
EVIDENCE SYNTHESIS: Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories.
CONCLUSIONS: Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.
KEY MESSAGES: - There is now extensive evidence demonstrating that there is a gap between the health care that patients receive and the practice that is recommended. In both primary and secondary care there are unwarranted variations in practice and in resulting outcomes that cannot be explained by the characteristics of patients.
- While it is difficult to find examples of measures for addressing this issue from all 53 countries of the World Health Organization’s European Region, there are interventions that can be identified in the 27 Member States of the European Union. However, the nature of these measures and the extent to which they are implemented vary considerably.
- Audit and feedback defined as “any summary of clinical performance of health care over a specified period of time aimed at providing information to health professionals to allow them to assess and adjust their performance” is an overarching term used to describe some of the measures that are used to improve professional practice.
- Audit and feedback can be used in all health care settings, involving all health professionals, either as individual professions or in multiprofessional teams.
- In practical terms, health professionals can receive feedback on their performance based on data derived from their routine practice. Health professionals involved in audit and feedback may work either in a team or individually and in primary, secondary or tertiary care.
- While it seems intuitive that health care professionals would be prompted to modify their clinical practice if receiving feedback that it was inconsistent with that of their peers or accepted guidelines, this is in fact not always the case.
- The available evidence suggests that audit and feedback may be effective in improving professional practice but that the effects are generally small to moderate. Nonetheless, depending on the context, such small effects, particularly if shown to be cost-effective, may still be regarded as worthwhile.
- The benefits of audit and feedback measures are most likely to occur where existing practice is furthest away from what is desired, and when feedback is more intensive.
- Even on the basis of the best evidence available, no strong recommendations can be given regarding the best way to introduce audit and feedback into routine practice. However, decisions about if, and how, this approach can Policy summary be used to improve professional practice must be guided by pragmatism and the consideration of local circumstances. The following scenarios, for example, might indicate suitability for such an approach: the known (or anticipated) level of initial adherence to guidelines or desired practice is low; it is feasible to conduct an audit and the associated costs of collecting the data are low; routinely collected data are reliable and appropriate for use in an audit; and small to moderate improvements in quality would be worthwhile.
- The cost of audit and feedback is highly variable and is determined by local conditions, including the availability of reliable routinely collected data and personnel costs.
- The impact of audit and feedback, with or without additional interventions, should be monitored routinely by auditing practice after the intervention.
There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven. Which of these are most effective remains unclear despite expressed concerns about potential for QIS-related patient harm and wasting of resources. The objective of this study was to review published literature assessing the relative effectiveness of different QIS. Data sources comprising PubMed Clinical Queries, Cochrane Library and its Effective Practice and Organization of Care database, and HealthStar were searched for studies of QIS between January 1985 and February 2008 using search terms based on an a priori QIS classification suggested by experts. Systematic reviews of controlled trials were selected in determining effect sizes for specific QIS, which were compared as a narrative meta-review. Clinician/patient driven QIS were associated with stronger evidence of efficacy and larger effect sizes than manager/policy-maker driven QIS. The most effective strategies (>10% absolute increase in appropriate care or equivalent measure) included clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders. Pay-for-performance schemes directed to clinician groups and organizational process redesign were modestly effective. Other manager/policy-maker driven QIS including continuous quality improvement programmes, risk and safety management systems, public scorecards and performance reports, external accreditation, and clinical governance arrangements have not been adequately evaluated with regard to effectiveness. QIS are heterogeneous and methodological flaws in much of the evaluative literature limit validity and generalizability of results. Based on current best available evidence, clinician/patient driven QIS appear to be more effective than manager/policy-maker driven QIS although the latter have, in many instances, attracted insufficient robust evaluations to accurately determine their comparative effectiveness.
OBJECTIVES: An evidence report was prepared to assess the evidence base regarding benefits and costs of health information technology (HIT) systems, that is, the value of discrete HIT functions and systems in various healthcare settings, particularly those providing pediatric care.
DATA SOURCES: PubMed, the Cochrane Controlled Clinical Trials Register, and the Cochrane Database of Reviews of Effectiveness (DARE) were electronically searched for articles published since 1995. Several reports prepared by private industry were also reviewed.
REVIEW METHODS: Of 855 studies screened, 256 were included in the final analyses. These included systematic reviews, meta-analyses, studies that tested a hypothesis, and predictive analyses. Each article was reviewed independently by two reviewers; disagreement was resolved by consensus.
RESULTS: Of the 256 studies, 156 concerned decision support, 84 assessed the electronic medical record, and 30 were about computerized physician order entry (categories are not mutually exclusive). One hundred twenty four of the studies assessed the effect of the HIT system in the outpatient or ambulatory setting; 82 assessed its use in the hospital or inpatient setting. Ninety-seven studies used a randomized design. There were 11 other controlled clinical trials, 33 studies using a pre-post design, and 20 studies using a time series. Another 17 were case studies with a concurrent control. Of the 211 hypothesis-testing studies, 82 contained at least some cost data. We identified no study or collection of studies, outside of those from a handful of HIT leaders, that would allow a reader to make a determination about the generalizable knowledge of the study's reported benefit. Beside these studies from HIT leaders, no other research assessed HIT systems that had comprehensive functionality and included data on costs, relevant information on organizational context and process change, and data on implementation. A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or cost-effectiveness of implementing such systems. The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context-specific information that can empower providers in their work. Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs. However, the predicted time needed to break even varied from three to as many as 13 years.
CONCLUSIONS: HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented.
To assess the comparative effectiveness of interventions for improving antibiotic use for acute respiratory tract infections (RTIs) in adults and children.
DATA SOURCES:
Electronic databases (MEDLINE(®) from 1990 and the Cochrane Library databases from 2005 to February 2015), reference lists of included systematic reviews, and Scientific Information Packets from point-of-care test manufacturers and experts.
REVIEW METHODS:
Using predefined criteria, we selected studies of any intervention designed to improve antibiotic use for acute RTIs for which antibiotics are not indicated. Interventions were organized into education, communication, clinical, system-level, and multifaceted categories. We identified interventions that had evidence of reducing resistance to antibiotics, improving appropriate prescribing (i.e., concordant with guidelines), or decreasing overall prescribing of antibiotics for acute RTIs and not causing adverse consequences such as medical complications or patient dissatisfaction. The quality of included studies was rated and the strength of the evidence was assessed. Clinical and methodological heterogeneity limited quantitative analysis.
RESULTS:
Although reduction in antibiotic resistance is a major goal of these interventions, there were too few studies to assess this outcome. The few studies that attempted to assess appropriate prescribing had important limitations and lack of consistency in outcome definition and ascertainment methods across studies. Therefore, reduction in overall prescribing was the only commonly reported benefit across interventions. Actual use of antibiotics was also reported in too few studies to assess separately from prescribing. No intervention had high-strength evidence for any outcome. The best evidence, from an evidence base of 133 studies, including 88 randomized controlled trials, was for four interventions with moderate-strength evidence of improved or reduced antibiotic prescribing compared with usual care that also had low-strength evidence of not causing adverse consequences. These were clinic-based parent education (21% overall prescribing reduction; similar return visits); public patient education campaigns combined with clinician education (improved appropriate prescribing; 7% reduction in overall prescribing; similar complications and satisfaction); procalcitonin for adults (12% to 72% overall prescribing reduction; similar continuing symptoms, limited activity, missing work, adverse events or lack of efficacy, treatment failure, hospitalizations, and mortality); and electronic decision support systems (improved appropriate prescribing and 5% to 9% reduction in overall prescribing; similar complications and health care use). Additionally, public parent education campaigns had low-strength evidence of reducing overall prescribing, not increasing diagnosis of complications, and decreasing subsequent visits. Other interventions had evidence of improved or reduced prescribing, but evidence on adverse consequences was lacking (streptococcal antigen testing, rapid multiviral testing in adults), insufficient (clinician and patient education plus audit and feedback plus academic detailing), or mixed (delayed prescribing, C-reactive protein [CRP] testing, clinician communication training, communication training plus CRP testing). Interventions with evidence of no impact on antibiotic prescribing were clinic-based education for parents of children 24 months or younger with acute otitis media, point-of-care testing for influenza or tympanometry in children, and clinician education combined with audit and feedback. Furthermore, limited evidence suggested that using adult procalcitonin algorithms in children is not effective and results in increased antibiotic prescribing.
CONCLUSIONS:
The best evidence supports the use of specific education interventions for patients/parents and clinicians, procalcitonin in adults, and electronic decision support to reduce overall antibiotic prescribing (and in some cases improve appropriate prescribing) for acute RTIs without causing adverse consequences, although the reduction in prescribing varied widely. Other interventions also reduced prescribing, but evidence on adverse consequences was lacking, insufficient, or mixed. Future studies should use a complex intervention framework and better evaluate measures of appropriate prescribing, adverse consequences such as hospitalization, sustainability, resource use, and the impact of potential effect modifiers. PROSPERO number: CRD42014010094.
