Roberto Grilli

Changing Provider Behavior: An Overview of Systematic Reviews of Interventions

Background.Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. Objectives.To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. Research design. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. Results.Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing) and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. Conclusions.Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.

Systematic reviews of the effectiveness of quality improvement strategies and programmes

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care (EPOC) review group.

EUR-ASSESS project subgroup report on dissemination and impact

The objective of health technology assessment (HTA) is to support decision making in health care. HTA does not claim to provide a definite solution to a health care problem, but to assist decision makers with evidence-based information about the clinical, ethical, social, and economic implications of the development, diffusion, and use of health care technology.Although technology assessments are primarily based on evidence of effectiveness from clinical research findings, they also contain cost-effectiveness analyses, discussions of organizational and managerial issues related to adopting the assessments recommendations, and policy analyses of the resources that are needed to implement the recommendations. Therefore, technology assessments contain information that will be interpreted differently depending on the context in which the assessment is implemented.Local circumstances, such as availability of personnel and financial resources, competition for limited resources, and the political situation, will influence the implementation of the findings of technology assessment. Cultural factors, such as the perceived importance of the subject of the technology assessment, attitudes toward technology, and acceptance of change, will also influence the adoption of recommendations from technology assessments.In this report of the EUR-ASSESS Subgroup on Dissemination and Impact, we strive to draw conclusions and make recommendations that will be useful to technology assessment programs in all European countries. However, organizations that attempt to implement the recommendations of this report must take the local and cultural circumstances of their regions into consideration.This report discusses several strategies for informing policy makers and communities of technology assessments:Diffusion is a passive process by which information is spread to an audience,Dissemination is an active process of spreading a message to defined target groups, andImplementation is a still more active process, including interventions to reduce or eliminate barriers to behavior change and/or activities to promote behavior change.In general, technology assessment organizations have given little attention to dissemination or implementation activities. However, as organizations have realized that the results of their assessments may have delayed or no impact on practice, dissemination has moved into the agenda.The goal of the report of the EUR-ASSESS Subgroup on Dissemination and Impact is to provide guidance to technology assessment programs in Europe on: a) the effective dissemination of the products of health care technology assessments programs; and b) the evaluation of the effects of such dissemination.The approach to this task was to: a) conduct a literature review to examine the evidence for the effectiveness of different methods of dissemination and implementation of research findings; b) conduct a survey to determine what technology assessment agencies are currently doing to disseminate and implement technology assessments; and c) describe a marketing strategy for disseminating technology assessments.This summary presents our methods and major conclusions. The overall conclusions of the report are rated according to the strength of the evidence on which they are based. The summary concludes with recommendations for technology assessment agencies that are derived from the major findings of the report as well as the practical experience of the committee members.

WITHDRAWN: Printed educational materials: effects on professional practice and health care outcomes.

BACKGROUNDnIt is often assumed that merely providing information in an accessible form will influence practice. Although such a strategy is still widely used in an attempt to change behaviour, there is a growing awareness that simply providing information may not lead to appropriate changes in the practice of health care professionals.nnnOBJECTIVESnTo assess the effects of printed educational materials in improving the behaviour of health care professionals and patient outcomes.nnnSEARCH STRATEGYnWe searched the Cochrane Effective Practice and Organisation of Care Group specialised register, reference lists of articles, and contacted content area experts.nnnSELECTION CRITERIAnRandomised trials, interrupted time series analyses and non equivalent group designs with pre-post measures of interventions comparing 1. Printed educational materials versus a non-intervention control; and 2. Printed educational materials plus additional implementation strategies versus printed educational materials alone. The participants were any health care professionals provided with printed educational materials aimed at improving their practice and/or patient outcomes.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently extracted data and assessed study quality.nnnMAIN RESULTSnEleven studies were included involving more than 1848 physicians. It proved impractical to examine the impact of interventions quantitatively because of poor reporting of results and inappropriate primary analyses. Nine studies examined comparison 1. Estimates of the benefit from printed educational materials ranged from -3% to 243.4% for provider outcomes, and from -16.1% to 175.6% for patient outcomes, although the practical importance of these changes is, at best, small. Six studies (seven comparisons) examined comparison 2. Benefits attributable to additional interventions ranged from -11.8% to 92.7% for professional behaviour, and -24.4% to 74.5% for patient outcomes. Two of the 14 estimates of professional behaviour, and two of the 11 estimates of patient outcomes were statistically significant.nnnAUTHORS CONCLUSIONSnThe effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved.

Interventions to reduce waiting times for elective procedures.

BACKGROUNDnLong waiting times for elective healthcare procedures may cause distress among patients, may have adverse health consequences and may be perceived as inappropriate delivery and planning of health care.nnnOBJECTIVESnTo assess the effectiveness of interventions aimed at reducing waiting times for elective care, both diagnostic and therapeutic.nnnSEARCH METHODSnWe searched the following electronic databases: Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1946-), EMBASE (1947-), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ABI Inform, the Canadian Research Index, the Science, Social Sciences and Humanities Citation Indexes, a series of databases via Proquest: Dissertations & Theses (including UK & Ireland), EconLit, PAIS (Public Affairs International), Political Science Collection, Nursing Collection, Sociological Abstracts, Social Services Abstracts and Worldwide Political Science Abstracts. We sought related reviews by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). We searched trial registries, as well as grey literature sites and reference lists of relevant articles.nnnSELECTION CRITERIAnWe considered randomised controlled trials (RCTs), controlled before-after studies (CBAs) and interrupted time series (ITS) designs that met EPOC minimum criteria and evaluated the effectiveness of any intervention aimed at reducing waiting times for any type of elective procedure. We considered studies reporting one or more of the following outcomes: number or proportion of participants whose waiting times were above or below a specific time threshold, or participants mean or median waiting times. Comparators could include any type of active intervention or standard practice.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently extracted data from, and assessed risk of bias of, each included study, using a standardised form and the EPOC Risk of bias tool. They classified interventions as follows: interventions aimed at (1) rationing and/or prioritising demand, (2) expanding capacity, or (3) restructuring the intake assessment/referral process.For RCTs when available, we reported preintervention and postintervention values of outcome for intervention and control groups, and we calculated the absolute change from baseline or the effect size with 95% confidence interval (CI). We reanalysed ITS studies that had been inappropriately analysed using segmented time-series regression, and obtained estimates for regression coefficients corresponding to two standardised effect sizes: change in level and change in slope.nnnMAIN RESULTSnEight studies met our inclusion criteria: three RCTs and five ITS studies involving a total of 135 general practices/primary care clinics, seven hospitals and one outpatient clinic. The studies were heterogeneous in terms of types of interventions, elective procedures and clinical conditions; this made meta-analysis unfeasible.One ITS study evaluating prioritisation of demand through a system for streamlining elective surgery services reduced the number of semi-urgent participants waiting longer than the recommended time (< 90 days) by 28 participants/mo, while no effects were found for urgent (< 30 days) versus non-urgent participants (< 365 days).Interventions aimed at restructuring the intake assessment/referral process were evaluated in seven studies. Four studies (two RCTs and two ITSs) evaluated open access, or direct booking/referral: One RCT, which showed that open access to laparoscopic sterilisation reduced waiting times, had very high attrition (87%); the other RCT showed that open access to investigative servicesxa0reduced waiting times (30%) for participants with lower urinary tract syndrome (LUTS) but had no effect on waiting times for participants with microscopic haematuria. In one ITS study, same-day scheduling for paediatric health clinic appointments reduced waiting times (direct reduction of 25.2 days, and thereafter a decrease of 3.03 days per month), while another ITS study showed no effect of a direct booking system on proportions of participants receiving a colposcopy appointment within the recommended time. One RCT and one ITS showed no effect of distant consultancy (instant photography for dermatological conditions and telemedicine for ear nose throat (ENT) conditions) on waiting times; another ITS study showed no effect of a pooled waiting list on the number of participants waiting for uncomplicated spinal surgery.Overall quality of the evidence for all outcomes, assessed using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) tool, ranged from low to very low.We found no studies evaluating interventions to increase capacity or to ration demand.nnnAUTHORS CONCLUSIONSnAs only a handful of low-quality studies are presently available, we cannot draw any firm conclusions about the effectiveness of the evaluated interventions in reducing waiting times. However, interventions involving the provision of more accessible services (open access or direct booking/referral) show some promise.

Processes, contexts, and rationale for disinvestment: a protocol for a critical interpretive synthesis

BackgroundPractical solutions are needed to support the appropriate use of available health system resources as countries are continually pressured to ‘do more with less’ in health care. Increasingly, health systems and organizations are exploring the reassessment of possibly obsolete, inefficient, or ineffective health system resources and potentially redirecting funds to those that are more effective and efficient. Such processes are often referred to as ‘disinvestment’. Our objective is to gain further understanding about: 1) whether how and under what conditions health systems decide to pursue disinvestment; 2) how health systems have chosen to undertake disinvestment; and 3) how health systems have implemented their disinvestment approach.Methods/DesignWe will use a critical interpretive synthesis (CIS) approach, to develop a theoretical framework based on insights drawn from a range of relevant sources. We will conduct systematic searches of databases as well as purposive searches to identify literature to fill conceptual gaps that may emerge during our inductive process of synthesis and analysis. Two independent reviewers will assess search results for relevance and conceptually map included references. We will include all empirical and non-empirical articles that focus on disinvestment at a system level. We will then extract key findings from a purposive sample of articles using frameworks related to government agendas, policy development and implementation, and health system contextual factors and then synthesize and integrate the findings to develop a framework about our core areas of interest. Lastly, we will convene a stakeholder dialogue with Canadian and international policymakers and other stakeholders to solicit targeted feedback about the framework (e.g., by identifying any gaps in the literature that we may want to revisit before finalizing it) and deliberating about barriers for developing and implementing approaches to disinvestment, strategies to address these barriers and about next steps that could be taken by different constituencies.DiscussionDisinvestment is an emerging field and there is a need for evidence to inform the prioritization, development, and implementation of strategies in different contexts. Our CIS and the framework developed through it will support the actions of those involved in the prioritization, development, and implementation of disinvestment initiatives.Systematic review registrationPROSPEROCRD42014013204