Healthcare professionals are important contributors to healthcare quality and patient
safety, but their performance does not always follow recommended clinical practice.
There are many approaches to influencing practice among healthcare professionals.
These approaches include audit and feedback, reminders, educational materials, educational
outreach visits, educational meetings or conferences, use of local opinion leaders,
financial incentives, and organisational interventions. In this review, we evaluated
the effectiveness of patient‐mediated interventions. These interventions are aimed
at changing the performance of healthcare professionals through interactions with
patients, or through information provided by or to patients. Examples of patient‐mediated
interventions include 1) patient‐reported health information, 2) patient information,
3) patient education, 4) patient feedback about clinical practice, 5) patient decision
aids, 6) patients, or patient representatives, being members of a committee or board,
and 7) patient‐led training or education of healthcare professionals. To assess the
effectiveness of patient‐mediated interventions on healthcare professionals' performance
(adherence to clinical practice guidelines or recommendations for clinical practice).
We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials
(CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials
Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google
Scholar in October 2017. We also screened the reference lists of included studies
and conducted cited reference searches for all included studies in October 2017. Randomised
studies comparing patient‐mediated interventions to either usual care or other interventions
to improve professional practice. Two review authors independently assessed studies
for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio
(RR) for dichotomous outcomes using Mantel‐Haenszel statistics and the random‐effects
model. For continuous outcomes, we calculated the mean difference (MD) using inverse
variance statistics. Two review authors independently assessed the certainty of the
evidence (GRADE). We included 25 studies with a total of 12,268 patients. The number
of healthcare professionals included in the studies ranged from 12 to 167 where this
was reported. The included studies evaluated four types of patient‐mediated interventions:
1) patient‐reported health information interventions (for instance information obtained
from patients about patients' own health, concerns or needs before a clinical encounter),
2) patient information interventions (for instance, where patients are informed about,
or reminded to attend recommended care), 3) patient education interventions (intended
to increase patients' knowledge about their condition and options of care, for instance),
and 4) patient decision aids (where the patient is provided with information about
treatment options including risks and benefits). For each type of patient‐mediated
intervention a separate meta‐analysis was produced. Patient‐reported health information
interventions probably improve healthcare professionals' adherence to recommended
clinical practice (moderate‐certainty evidence). We found that for every 100 patients
consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical
practice compared to 17 per 100 in the comparison group (no intervention or usual
care). We are uncertain about the effect of patient‐reported health information interventions
on desirable patient health outcomes and patient satisfaction (very low‐certainty
evidence). Undesirable patient health outcomes and adverse events were not reported
in the included studies and resource use was poorly reported. Patient information
interventions may improve healthcare professionals' adherence to recommended clinical
practice (low‐certainty evidence). We found that for every 100 patients consulted
or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice
compared to 20 per 100 in the comparison group (no intervention or usual care). Patient
information interventions may have little or no effect on desirable patient health
outcomes and patient satisfaction (low‐certainty evidence). We are uncertain about
the effect of patient information interventions on undesirable patient health outcomes
because the certainty of the evidence is very low. Adverse events and resource use
were not reported in the included studies. Patient education interventions probably
improve healthcare professionals' adherence to recommended clinical practice (moderate‐certainty
evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39
to 54) are in accordance with recommended clinical practice compared to 35 per 100
in the comparison group (no intervention or usual care). Patient education interventions
may slightly increase the number of patients with desirable health outcomes (low‐certainty
evidence). Undesirable patient health outcomes, patient satisfaction, adverse events
and resource use were not reported in the included studies. Patient decision aid interventions
may have little or no effect on healthcare professionals' adherence to recommended
clinical practice (low‐certainty evidence). We found that for every 100 patients consulted
or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice
compared to 37 per 100 in the comparison group (usual care). Patient health outcomes,
patient satisfaction, adverse events and resource use were not reported in the included
studies. We found that two types of patient‐mediated interventions, patient‐reported
health information and patient education, probably improve professional practice by
increasing healthcare professionals' adherence to recommended clinical practice (moderate‐certainty
evidence). We consider the effect to be small to moderate. Other patient‐mediated
interventions, such as patient information may also improve professional practice
(low‐certainty evidence). Patient decision aids may make little or no difference to
the number of healthcare professionals' adhering to recommended clinical practice
(low‐certainty evidence). The impact of these interventions on patient health and
satisfaction, adverse events and resource use, is more uncertain mostly due to very
low certainty evidence or lack of evidence. What is the aim of the review? Our aim
with this Cochrane review was to assess whether patients can change the performance
of healthcare professionals. We collected and analysed all relevant studies to answer
this question and found 25 studies. Key message This review suggests that patients
may change healthcare professionals’ practice though the following three strategies:
1) strategies where patients give healthcare professionals information about themselves;
2) strategies where patients are given healthcare information; and 3) strategies where
patients take part in patient education. Patient decision aids may make little or
no difference to healthcare professionals’ practice, however, the certainty is low,
and these results should be interpreted carefully. We still need more research about
the best ways in which patients can change professional practice and about the impact
it has on patients’ health. What was studied in the review? Many strategies have been
tested to see if they can improve healthcare professionals’ practice and make sure
that patients receive the best available care. These strategies include sending reminders
to healthcare professionals, giving them further education, or giving them financial
rewards. These strategies have mostly had only small or moderate effects. Another
way of changing what healthcare professionals do is through the patients themselves.
These strategies are called 'patient‐mediated interventions'. What are the main results
of the review? The studies in this review assessed different patient‐mediated strategies
compared to usual care or no strategies. Strategies where patients give information
to healthcare professionals In these studies, patients gave information about their
own health, concerns or needs to the doctor. This was usually done by filling in a
questionnaire in the waiting area before a consultation. The doctor was then given
this information before or at the consultation. The review shows that these strategies:
‐ probably improve the extent to which healthcare professionals follow recommended
clinical practice (moderate‐certainty evidence). We are uncertain about the effect
of these strategies on patient health, patient satisfaction and resource use because
these outcomes were not measured in the studies or because the certainty of the evidence
is very low. Strategies where information was given to patients In these studies,
patients were given information about recommended care or were reminded to use services,
for instance to go for a check‐up. The review shows that these strategies: ‐ may improve
the extent to which healthcare professionals follow recommended clinical practice
(low‐certainty evidence); ‐ may have little or no effect on patient satisfaction (low‐certainty
evidence); ‐ may have little or no effect on some patient health outcomes, such as
the number of patients who reach controlled blood pressure (low‐certainty evidence).
However, we are uncertain about the effect of these strategies on other patient health
outcomes because the certainty of the evidence is very low. We also lack information
to draw conclusions about resource use. Patient education strategies In these studies,
patients took part in patient education such as self‐management programmes, for instance
to increase their knowledge about their condition. The review shows that these strategies:
‐ probably improve the extent to which healthcare professionals follow recommended
clinical practice (moderate‐certainty evidence); ‐ may slightly improve some patient
health outcomes such as the number of patients who reach controlled blood pressure
(low‐certainty evidence). However, we are uncertain about the effect of these strategies
on other patient health outcomes, patient satisfaction and resource use because these
outcomes were not measured in the included studies. Patient decision aid strategies
In the one study that assessed effect of patient decision aids, patients were given
a decision aid consisting of a booklet, personal worksheet, and audiotape to make
decisions about their medical management. The review shows that these strategies:
‐ may have little or no effect on the extent to which healthcare professionals follow
recommended clinical practice (low‐certainty evidence) We are uncertain about the
effect of these strategies on patient health, patient satisfaction and resource use
because these outcomes were not measured in the studies or because the certainty of
the evidence is very low. How up‐to‐date is this review? We searched for studies up
to March 2018 and ongoing studies up to October 2017.