Rebecca Ryan

Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review

Objective To assess the effects on patients, clinicians, and the healthcare system of interventions before consultations to help patients or their representatives gather information in consultations by question asking. Design Systematic review with meta-analysis. Data sources Electronic literature searches of seven databases and hand searching of one journal and bibliographies of relevant articles. Review methods Inclusion criteria included randomised controlled trials. Main outcome measures Primary outcomes were question asking; patients’ anxiety, knowledge, and satisfaction; and length of consultation. Results 33 randomised trials of variable quality involving 8244 patients were identified. A few studies showed positive effects. Meta-analyses showed small and statistically significantly increases in question asking (standardised mean difference 0.27, 95% confidence interval 0.19 to 0.36) and patients’ satisfaction (0.09, 0.03 to 0.16). Non-statistically significant changes occurred in patients’ anxiety before consultations (weighted mean difference −1.56, −7.10 to 3.97), patients’ anxiety after consultations (standardised mean difference −0.08, −0.22 to 0.06), patients’ knowledge (−0.34, −0.94 to 0.25), and length of consultation (0.10, −0.05 to 0.25). Interventions comprising written materials had similar effects on question asking, consultation length, and patients’ satisfaction as those comprising the coaching of patients. Interventions with additional training of clinicians had little further effect than those targeted at patients alone for patients’ satisfaction and consultation length. Conclusions Interventions for patients before consultations produce small benefits for patients. This may be because patients and clinicians have established behaviours in consultations that are difficult to change. Alternatively small increases in question asking may not be sufficient to make notable changes to other outcomes.

Absolute risk representation in cardiovascular disease prevention: comprehension and preferences of health care consumers and general practitioners involved in a focus group study.

BackgroundCommunicating risk is part of primary prevention of coronary heart disease and stroke, collectively referred to as cardiovascular disease (CVD). In Australia, health organisations have promoted an absolute risk approach, thereby raising the question of suitable standardised formats for risk communication.MethodsSixteen formats of risk representation were prepared including statements, icons, graphical formats, alone or in combination, and with variable use of colours. All presented the same risk, i.e., the absolute risk for a 55 year old woman, 16% risk of CVD in five years. Preferences for a five or ten-year timeframe were explored. Australian GPs and consumers were recruited for participation in focus groups, with the data analysed thematically and preferred formats tallied.ResultsThree focus groups with health consumers and three with GPs were held, involving 19 consumers and 18 GPs.Consumers and GPs had similar views on which formats were more easily comprehended and which conveyed 16% risk as a high risk. A simple summation of preferences resulted in three graphical formats (thermometers, vertical bar chart) and one statement format as the top choices. The use of colour to distinguish risk (red, yellow, green) and comparative information (age, sex, smoking status) were important ingredients. Consumers found formats which combined information helpful, such as colour, effect of changing behaviour on risk, or comparison with a healthy older person. GPs preferred formats that helped them relate the information about risk of CVD to their patients, and could be used to motivate patients to change behaviour.Several formats were reported as confusing, such as a percentage risk with no contextual information, line graphs, and icons, particularly those with larger numbers.Whilst consumers and GPs shared preferences, the use of one format for all situations was not recommended. Overall, people across groups felt that risk expressed over five years was preferable to a ten-year risk, the latter being too remote.ConclusionsConsumers and GPs shared preferences for risk representation formats. Both groups liked the option to combine formats and tailor the risk information to reflect a specific individuals risk, to maximise understanding and provide a good basis for discussion.

Building blocks for meta-synthesis : data integration tables for summarising, mapping, and synthesising evidence on interventions for communicating with health consumers.

BackgroundSystematic reviews have developed into a powerful method for summarising and synthesising evidence. The rise in systematic reviews creates a methodological opportunity and associated challenges and this is seen in the development of overviews, or reviews of systematic reviews. One of these challenges is how to summarise evidence from systematic reviews of complex interventions for inclusion in an overview. Interventions for communicating with and involving consumers in their care are frequently complex. In this article we outline a method for preparing data integration tables to enable review-level synthesis of the evidence on interventions for communication and participation in health.Methods and ResultsSystematic reviews published by the Cochrane Consumers and Communication Review Group were utilised as the basis from which to develop linked steps for data extraction, evidence assessment and synthesis. The resulting output is called a data integration table. Four steps were undertaken in designing the data integration tables: first, relevant information for a comprehensive picture of the characteristics of the review was identified from each review, extracted and summarised. Second, results for the outcomes of the review were assessed and translated to standardised evidence statements. Third, outcomes and evidence statements were mapped into an outcome taxonomy that we developed, using language specific to the field of interventions for communication and participation. Fourth, the implications of the review were assessed after the mapping step clarified the level of evidence available for each intervention.ConclusionThe data integration tables represent building blocks for constructing overviews of review-level evidence and for the conduct of meta-synthesis. Individually, each table aims to improve the consistency of reporting on the features and effects of interventions for communication and participation; provides a broad assessment of the strength of evidence derived from different methods of analysis; indicates a degree of certainty with results; and reports outcomes and gaps in the evidence in a consistent and coherent way. In addition, individual tables can serve as a valuable tool for accurate dissemination of large amounts of complex information on communication and participation to professionals as well as to members of the public.

The Rx for Change database: a first-in-class tool for optimal prescribing and medicines use

BackgroundGlobally, suboptimal prescribing practices and medication errors are common. Guidance to health professionals and consumers alone is not sufficient to optimise behaviours, therefore strategies to promote evidence-based decision making and practice, such as decision support tools or reminders, are important. The literature in this area is growing, but is of variable quality and dispersed across sources, which makes it difficult to identify, access, and assess. To overcome these problems, by synthesizing and evaluating the data from systematic reviews, we have developed Rx for Change to provide a comprehensive, online database of the evidence for strategies to improve drug prescribing and use.MethodsWe use reliable and valid methods to search and screen the literature, and to appraise and analyse the evidence from relevant systematic reviews. We then present the findings in an online format which allows users to easily access pertinent information related to prescribing and medicines use. The database is a result of the collaboration between the Canadian Agency for Drugs and Technologies in Health (CADTH) and two Cochrane review groups.ResultsTo capture the body of evidence on interventions to improve prescribing and medicines use, we conduct comprehensive and regular searches in multiple databases, and hand-searches of relevant journals. We screen articles to identify relevant systematic reviews, and include them if they are of moderate or high methodological quality. Two researchers screen, assess quality, and extract data on demographic details, intervention characteristics, and outcome data. We report the results of our analysis of each systematic review using a standardised quantitative and qualitative format. Rx for Change currently contains over 200 summarised reviews, structured in a multi-level format. The reviews included in the database are diverse, covering various settings, conditions, or diseases and targeting a range of professional and consumer behaviors.ConclusionsRx for Change is a novel database that synthesizes current research evidence about the effects of interventions to improve drug prescribing practices and medicines use.

A Systematic Review of Consumer-Providers’ Effects on Client Outcomes in Statutory Mental Health Services: The Evidence and the Path Beyond

Consumer-provider involvement in the delivery of mental health services has steadily increased in the past several decades; however, the effects on client and service outcomes have remained unclear. The objectives of this paper are to (a) summarize a Cochrane review of consumer-providers’ effects on client outcomes in statutory mental health services and (b) discuss several key issues that, if addressed, might strengthen evidence in this area. We searched The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, and Current Contents until March 2012 to identify relevant studies. Studies were eligible for inclusion if they randomized adult clients to statutory mental health services delivered with and without consumer-provider involvement. Eleven studies met the eligibility criteria and were divided into 2 separate comparison groups: studies comparing consumer-providers with professionals employed in the same role within a mental health service (5 studies) and studies comparing mental health services with and without consumer-providers as an adjunct to the service (6 studies). The limited outcome data available from the studies indicated no difference in quality of life, function, social relations, mental health symptoms, client satisfaction, or attrition in those receiving services from consumer-providers compared with those who did not. None of the studies reported any adverse outcomes for clients. Addressing several key issues could strengthen the evidence such as: core outcome measures, appropriate study designs for evaluating complex interventions, minimal cross-contamination of treatment groups for community-based interventions, improved trial reporting, and the use of systematic reviews to inform future research.

Making rational choices about how best to support consumers’ use of medicines: a perspective review

Inappropriate medicine use and polypharmacy create significant challenges for consumers and the health systems they live in, worldwide. In this review, we describe the evidence underpinning interventions directed primarily at healthcare consumers, including information provision, pharmacist-delivered interventions and practical supports, such as reminders to improve outcomes related to medicines. We identify a relatively small number of strategies that seem effective or promising: self-monitoring and self-management programmes, simplified dosing regimens and pharmacist-delivered interventions such as medication review. These interventions could be applied in practice to address some of the problems associated with inappropriate use of medicines, multimorbidity and polypharmacy. The evidence also indicates that success with many strategies is not consistent, suggesting that understanding the individual’s context and their preferences will also be important for improving medicines’ use. In addition, some strategies in current use are ineffective. Taken together, we argue that the evidence should inform deliberate, rational decisions between strategies to support consumers in using medicines safely and effectively. Future medicine-use research should likewise build rationally and constructively on what is known about promising interventions, avoiding duplication of past research, and working to help consumers negotiate the many challenges presented by polypharmacy.

Improving the experiences and health of people with multimorbidity: exploratory research with policymakers and information providers on comorbid arthritis

Multimorbidity has emerged as a complex health issue with the burden falling predominantly on patients, families and the primary health care sector. Evidence-informed communication and participation, activities informed by evidence and peoples views and experiences, has the potential to improve health outcomes for people with multimorbidity. In recognition of their role in shaping future actions, we conducted focus groups with policymakers and information providers. The aim of this article is to report on the range and impacts of communication problems in multimorbidity, and identify points of intervention. To facilitate and focus dialogue, comorbid arthritis was selected as the case example. Two focus groups were held: one with policymakers and the other with health information providers. Participants were asked to discuss communication problems and possibilities relevant to multimorbidity, using examples from comorbid arthritis where relevant. Participants highlighted three main areas on which to focus future efforts to improve the health outcomes and experiences of people with multimorbidity: (1) make explicit the problems of multimorbidity and communication; (2) recognise that both multimorbidity and communication issues are compounding factors; and (3) consider actions at policy, service, community and individual levels. Examining multimorbidity through the lens of communication issues identified the significant burden across different domains of the health system. The focus on communication may facilitate a cross-disease perspective to emerge and assist with policy development.

Evidence on optimal prescribing and medicines use for decision makers: Scope and application of the 'Rx for change' database

Rx for Change, a freely available online database, summarises the evidence on the impact of interventions to improve the quality of prescribing and medicines use. The database serves as a resource for decision makers seeking to find and use the evidence from systematic reviews on interventions to improve prescribing and medicines use by targeting the behaviours of health professionals and consumers. We describe a panel discussion held in 2010 on the databases scope and application. Panellists explored the ways decision makers might use the database to access the evidence as an input to decision making; and presented examples of the range of interventions on which evidence is assembled within the Rx for Change database and through which professional and consumer behaviours might be targeted to improve prescribing and medicines use.

Cochrane review - interventions to improve safe and effective medicines use by consumers: an overview of systematic review

It is three years since we published the first version of this overview (1), and it is grown considerably in that time. In 2011, it included 37 systematic reviews and applying the same methods as before, we found 38 more reviews, taking the total analyzed in the overview to 75 (2). This means that we are drawing together research from studies with thousands of people. Unfortunately, though, the evidence continues to be very sparse for the effect of interventions in some populations, including children and young people, family carers, or people with more than one health problem. Updating the overview has strengthened some of our initial conclusions and identified some promising new findings. But, before taking you through these, we would like to explain why we did the overview. Medicines can be a challenge for many people and helping people take them safely and effectively is a major goal of health systems everywhere. Thinking about the term safely and effectively, we mean that consumers know and understand what to do, acquire the necessary skills and support to manage their medicines, take their medicines, and their health improves as a result. Many different types of communication-related interventions are used to ensure people achieve this. Some of the most basic interventions include written information pamphlets, or simplifying how often people have to take their medicines. More complex interventions include training programs for people to learn how to adjust and administer the right dose, or training and a personal review of a person’s medicines undertaken by a pharmacist. We included a large range of interventions in the overview because governments, health services, health professionals, and consumers need to know what the evidence can tell us about all of these different communication strategies. It is not possible to present all our findings here, but the main ones are: Interventions that are generally effective are learning how to self-monitor dosing levels or self-manage medicines. These interventions lead to improved medicine use, improved adherence, fewer adverse events, and improved clinical outcomes. They may reduce premature death in people taking antithrombotic medicine, in cases where people are comfortable self-monitoring. There are two types of interventions where the evidence shows promise .These are simplified dosing—for instance, the frequency of doses is simplified from four times a day to two, which may improve adherence; and interventions involving pharmacists, such as conducting an assessment of all the medicines a person is taking. This may improve adherence, reduce medicine problems, and improve clinical outcomes. Simple interventions, such as giving a patient a written medicines information pamphlet does not lead to improvements in adherence but it may increase a person’s knowledge—in itself a precursor to appropriate health care behavior. This overview is important because most health systems are pursuing high-quality and safe health care, but with more limited resources, and medicines are a major cost for many individuals and for governments. The research we have compiled shows that there are many preventable problems which could be avoided through better communication or by having the right knowledge, skills, and support. By bringing all the relevant systematic reviews together in one place, our aim is to improve decision making in health systems, which in turn will improve health.

Notification and support for people exposed to the risk of Creutzfeldt-Jakob disease (CJD) through medical treatment (iatrogenically)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To evaluate the eDects of interventions to notify and support consumers (patients and their carers or families) in situations where exposure to the risk of CJD or vCJD has occurred as a result of medical treatment (iatrogenically), on consumer, carer, healthcare provider and healthcare system outcomes. Notification and support for people exposed to the risk of Creutzfeldt-Jakob disease (CJD) through medical treatment (iatrogenically) (Protocol) Copyright