Background and OBJECTIVE: Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers’ adherence to asthma guidelines on health care process and clinical outcomes. METHODS: Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence. RESULTS: Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (<i>n</i> = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance. CONCLUSIONS: Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
OBJECTIVES: To synthesize the published literature on the effect of interventions designed to improve health care providers' adherence to asthma guidelines on: (1) health care process outcomes (Key Question 1); (2) clinical outcomes (Key Question 2); (3) health care processes that subsequently impact clinical outcomes (Key Question 3).
DATA SOURCES: Reports of studies from MEDLINE(®), Embase(®), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL(®)), Educational Resources Information Center (ERIC(sm)), PsycINFO(®), and Research and Development Resource Base in Continuing Medical Education (RDRB/CME), up to July 2012.
REVIEW METHODS: Paired investigators independently reviewed each title, abstract, and full-text article to assess eligibility. Only comparative studies were eligible. Investigators abstracted data sequentially and independently graded the evidence.
RESULTS: A total of 73 studies were eligible for review. A slight majority of studies were conducted in the U.S. (n=38). We classified studies as assessing eight types of interventions: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement (QI)/pay-for-performance, multicomponent, and information only. Half of the studies were randomized trials (n=34), 29 were pre-post, and the remaining 10 were a variety of nonrandomized study designs. The studies took place exclusively in primary care settings. The most frequently cited health care process outcome was prescription of asthma controller medication (n=41), followed by provision of an asthma action plan (n=18), prescription of a peak flow meter (n=17), and self-management education (n=12). Common clinical outcomes included emergency department (ED) visits (n=30) and hospitalizations (n=27), followed by use of short-acting β2 agonists (n=9), missed school days (n=8), lung function tests (n=6), symptom days (n=6), quality of life (n=5), and urgent doctor visits (n=5). We identified 4 critical outcomes for which 68 studies provided information. There was moderate evidence for increased prescriptions of asthma controller medications using decision support, feedback and audit, and clinical pharmacy support interventions and low grade evidence for organizational change, multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans; for the same outcome, low grade evidence supports the use of organizational change, feedback and audit, education only, quality improvement, and multicomponent interventions. Moderate grade evidence supports use of decision support tools to reduce ED visits/hospitalizations while low grade evidence suggests there is no benefit associated with organizational change, education only, and QI/pay-for-performance. Organizational change interventions provided no benefit for lost days of work/school. The evidence for the remainder of interventions was insufficient or low in strength.
CONCLUSIONS: There is low to moderate evidence to support the use of decision support tools, feedback and audit, and clinical pharmacy support to improve the adherence of health care providers to asthma guidelines, as measured through health care process outcomes, and to improve clinical outcomes. There is a need to further evaluate health care provider-targeted interventions with a focus on standardized measures of outcomes and more rigorous study designs.
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.
BACKGROUND: Educational interventions have long been used as a means of influencing prescribing behavior. Various techniques including educational mailings, academic detailing, prescriber feedback with or without disclosing patient-identifying data, and supplemental patient information have been used to promote appropriate prescribing habits, reduce costs, and optimize patient care. While the effects of educational intervention programs are widely reported, little information is available regarding the effectiveness of various mailed intervention techniques.
OBJECTIVE: To review the effectiveness of mailed intervention programs and identify factors that may promote successful outcomes.
METHODS: A literature search was conducted via PubMed for reports of mailed intervention programs published through May 2012. Specific search terms included "drug utilization review," "drug utilization," "Medicaid," "prescribing feedback," "mailed physician intervention," and "mailed physician communications." Identified publications that met the following criteria were selected for inclusion: (a) evaluated printed educational materials disseminated via postal mail, (b) occurred in an outpatient setting, and (c) measured intervention impact on prescribing patterns, health care utilization, or economic outcomes. Publications that met all 3 criteria were abstracted for intervention strategy, follow-up period, data source, intervention target, prescriber acceptance of intervention, and effect on prescribing patterns, health care utilization, and economic outcomes.
RESULTS: A total of 40 published reports regarding 39 unique interventions met inclusion criteria. The majority (34/39 [87.2%]) of studies were conducted in state or federally funded programs; only 5 programs involved private insurers. All programs used follow-up periods of ≤12 months after final intervention mailing. A total of 26 of the 39 unique interventions reported a positive impact on at least 1 target outcome. Programs that included a second recipient such as pharmacists (n = 4) reported a greater impact as compared with interventions mailed to prescribers alone. Programs that provided patient-identifying data had a higher success rate than those that supplied prescriber feedback and/or educational materials (21/25 [84.0%] vs. 5/14 [35.7%]); it should be noted that 2 of the 5 successful programs that provided nonpatient-identifying materials also used academic detailing. Programs that sent education material and/or prescriber feedback pertaining to multiple medication classes or disease states had minimal impact on prescribing patterns (n = 4). However, targeting 1 specific disease or medication supported by appropriate evidence resulted in favorable change in a short period of time. Additionally, providing recommendations that were supported by widely accepted clinical guidelines or literature were also associated with a high rate of success. A subset of programs that sought to evaluate health care utilization (n=5) and economic impact (n = 9) observed little change in measured outcomes. Evaluation of prescriber response forms conducted by 7 programs revealed that changes in therapy occurred in approximately 50% of patients with prescribers who intended to accept intervention recommendations.
CONCLUSIONS: Though the degree of heterogeneity between articles prevents provision of definite results, it appears that a well-constructed mailed intervention program has the potential to evoke significant changes in prescribing patterns. Prescribers appear to be receptive to mailed interventions; however, there are limited data to determine the association between acceptance and actual prescribing change. Future research should focus on identifying barriers that may prohibit acceptance of recommendations from translating into changes in therapy. Additionally, future projects should include longer assessment periods to determine the duration of impact following final intervention mailing and potential effect on health care and economic outcomes.
OBJECTIVE: To determine (1) how medical registries provide information feedback to health care professionals, (2) whether this feedback has any effect on the quality of care and (3) what the barriers and success factors are to the effectiveness of feedback.
DATA SOURCES: Original articles in English found in MEDLINE Pubmed covering the period January 1990 to August 2007.
REVIEW METHOD: Titles and abstracts of 6223 original articles were independently screened by two reviewers to determine relevance for further review.
DATA EXTRACTION AND ANALYSIS: We used a standardized data abstraction form to collect information on the feedback initiatives and their effectiveness. The effect of the feedback was only described for analytic papers, i.e. papers that attempted to objectively quantify the effect on the quality of care and to relate this effect to feedback as an intervention. For analysis of the effectiveness, we categorized the initiatives based on the number of elements added to the feedback.
RESULTS: We included 53 papers, describing 50 feedback initiatives, of which 39 were part of a multifaceted approach. Our results confirm previous research findings that adding elements to a feedback strategy positively influences its effectiveness. We found 22 analytic studies, four of which found a positive effect on all outcome measures, eight found a mix of positive- and no effects and ten did not find any effects (neither positive nor negative). Of the 43 process of care measures evaluated in the analytic studies, 26 were positively affected by the feedback initiative. Of the 36 evaluated outcome of care measures, five were positively affected. The most frequently mentioned factors influencing the effectiveness of the feedback were: (trust in) quality of the data, motivation of the recipients, organizational factors and outcome expectancy of the feedback recipients.
CONCLUSIONS: The literature on methods and effects of information feedback by medical registries is heterogeneous, making it difficult to draw definite conclusions on its effectiveness. However, the positive effects cannot be discarded. Although our review confirms findings from previous studies that process of care measures are more positively influenced by feedback than outcome of care measures, further research should attempt to identify outcome of care measures that are sensitive to behaviour change as a result of feedback strategies. Furthermore, future studies evaluating the effectiveness of feedback should include a more extensive description of their intervention in order to increase the reproducibility of feedback initiatives and the generalizability of the results.
OBJECTIVES: To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care.
METHODS: We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia.
RESULTS: The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members.
CONCLUSION: The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care.
Background: Many people advocate audit and feedback as a strategy for improving professional practice. The main results of an update of a Cochrane review on the effects of audit and feedback are reported. Data sources: The Cochrane Effective Practice and Organisation of Care Group's register up to January 2004 was searched. Randomised trials of audit and feedback that reported objectively measured professional practice in a healthcare setting or healthcare outcomes were included. Review methods: Data were independently extracted and the quality of studies were assessed by two reviewers. Quantitative, visual and qualitative analyses were undertaken. Main results: 118 trials are included in the review. In the primary analysis, 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback was a component to no intervention. For dichotomous outcomes, the median-adjusted risk difference of compliance with desired practice was 5% (interquartile range 3-11). For continuous outcomes, the median-adjusted percentage change relative to control was 16% (interquartile range 5-37). Low baseline compliance with recommended practice and higher intensity of audit and feedback appeared to predict the effectiveness of audit and feedback. Conclusions: Audit and feedback can be effective in improving professional practice. The effects are generally small to moderate. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.
BACKGROUND AND CONTEXT: There is a basis for the assumption that feedback can be used to enhance physicians' performance. Nevertheless, the findings of empirical studies of the impact of feedback on clinical performance have been equivocal.
OBJECTIVES: To summarize evidence related to the impact of assessment and feedback on physicians' clinical performance.
SEARCH STRATEGY: The authors searched the literature from 1966 to 2003 using MEDLINE, HealthSTAR, the Science Citation Index and eight other electronic databases. A total of 3702 citations were identified.
INCLUSION AND EXCLUSION CRITERIA: Empirical studies were selected involving the baseline measurement of physicians' performance and follow-up measurement after they received summaries of their performance.
DATA EXTRACTION: Data were extracted on research design, sample, dependent and independent variables using a written protocol.
DATA SYNTHESIS: A group of 220 studies involving primary data collection was identified. However, only 41 met all selection criteria and evaluated the independent effect of feedback on physician performance. Of these, 32 (74%) demonstrated a positive impact. Feedback was more likely to be effective when provided by an authoritative source over an extended period of time. Another subset of 132 studies examined the effect of feedback combined with other interventions such as educational programmes, practice guidelines and reminders. Of these, 106 studies (77%) demonstrated a positive impact. Two additional subsets of 29 feedback studies involving resident physicians in training and 18 studies examining proxy measures of physician performance across clinical sites or groups of patients were reviewed. The majority of these two subsets also reported that feedback had positive effects on performance.
HEADLINE RESULTS: Feedback can change physicians' clinical performance when provided systematically over multiple years by an authoritative, credible source.
CONCLUSIONS: The effects of formal assessment and feedback on physician performance are influenced by the source and duration of feedback. Other factors, such as physicians' active involvement in the process, the amount of information reported, the timing and amount of feedback, and other concurrent interventions, such as education, guidelines, reminder systems and incentives, also appear to be important. However, the independent contributions of these interventions have not been well documented in controlled studies. It is recommended that the designers of future theoretical as well as practical studies of feedback separate the effects of feedback from other concurrent interventions.
Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers’ adherence to asthma guidelines on health care process and clinical outcomes.
METHODS:
Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence.
RESULTS:
Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance.
CONCLUSIONS:
Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
