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      Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in children and adults with overweight or obesity

      1 , 2 , 3

      Cochrane Effective Practice and Organisation of Care Group

      Cochrane Database of Systematic Reviews

      Wiley

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          Abstract

          The prevalence of overweight and obesity is increasing globally, an increase which has major implications for both population health and costs to health services. This is an update of a Cochrane Review. To assess the effects of strategies to change the behaviour of health professionals or the organisation of care compared to standard care, to promote weight reduction in children and adults with overweight or obesity. We searched the following databases for primary studies up to September 2016: CENTRAL, MEDLINE, Embase, CINAHL, DARE and PsycINFO. We searched the reference lists of included studies and two trial registries. We considered randomised trials that compared routine provision of care with interventions aimed either at changing the behaviour of healthcare professionals or the organisation of care to promote weight reduction in children and adults with overweight or obesity. We used standard methodological procedures expected by Cochrane when conducting this review. We report the results for the professional interventions and the organisational interventions in seven 'Summary of findings' tables. We identified 12 studies for inclusion in this review, seven of which evaluated interventions targeting healthcare professional and five targeting the organisation of care. Eight studies recruited adults with overweight or obesity and four recruited children with obesity. Eight studies had an overall high risk of bias, and four had a low risk of bias. In total, 139 practices provided care to 89,754 people, with a median follow‐up of 12 months. Professional interventions Educational interventions aimed at general practitioners (GPs), may slightly reduce the weight of participants (mean difference (MD) ‐1.24 kg, 95% confidence interval (CI) ‐2.84 to 0.37; 3 studies, N = 1017 adults; low‐certainty evidence). Tailoring interventions to improve GPs' compliance with obesity guidelines probably leads to little or no difference in weight loss (MD 0.05 (kg), 95% CI ‐0.32 to 0.41; 1 study, N = 49,807 adults; moderate‐certainty evidence). It is uncertain if providing doctors with reminders results in a greater weight reduction than standard care (men: MD ‐11.20 kg, 95% CI ‐20.66 kg to ‐1.74 kg, and women: MD ‐1.30 kg, 95% CI [‐7.34, 4.74] kg; 1 study, N = 90 adults; very low‐certainty evidence). Providing clinicians with a clinical decision support (CDS) tool to assist with obesity management at the point of care leads to little or no difference in the body mass index (BMI) z‐score of children (MD ‐0.08, 95% CI ‐0.15 to ‐0.01 in 378 children; moderate‐certainty evidence), CDS tools may lead to little or no difference in weight loss in adults: MD ‐0.095 kg (‐0.21 lbs), P = 0.47; 1 study, N = 35,665; low‐certainty evidence. Organisational interventions Adults with overweight or obesity may lose more weight if the care was provided by a dietitian (by ‐5.60 kg, 95% CI ‐4.83 kg to ‐6.37 kg) or by a doctor‐dietitian team (by ‐6.70 kg, 95% CI ‐7.52 kg to ‐5.88 kg; 1 study, N = 270 adults; low‐certainty evidence). Shared care leads to little or no difference in the BMI z‐score of children with obesity (adjusted MD ‐0.05, 95% CI ‐0.14 to 0.03; 1 study, N = 105 children; low‐certainty evidence). Organisational restructuring of the delivery of primary care (i.e. introducing the chronic care model) may result in a slightly lower increase in the BMI of children who received care at intervention clinics (BMI change: adjusted MD ‐0.21, 95% CI ‐0.50 to 0.07; 1 study, unadjusted MD ‐0.18, 95% CI ‐0.20 to ‐0.16; N=473 participants; moderate‐certainty evidence). Mail and phone interventions probably lead to little or no difference in weight loss in adults (mean weight change (kg) using mail: ‐0.36, 95% CI ‐1.18 to 0.46; phone: ‐0.44, 95% CI ‐1.26 to 0.38; 1 study, N = 1801 adults; moderate‐certainty evidence). Care delivered by a nurse at a primary care clinic may lead to little or no difference in the BMI z‐score in children (MD ‐0.02, 95% CI ‐0.16 to 0.12; 1 study, N = 52 children; very low‐certainty evidence). Two studies reported data on cost effectiveness: one study favoured mail and standard care over telephone consultations, and the other study achieved weight loss at a modest cost in both intervention groups (doctor and doctor‐dietitian). One study of shared care reported similar adverse effects in both groups. We found little convincing evidence for a clinically‐important effect on participants' weight or BMI of any of the evaluated interventions. While pooled results from three studies indicate that educational interventions targeting healthcare professionals may lead to a slight weight reduction in adults, the certainty of these results is low. Two trials evaluating CDS tools (unpooled results) for improved weight management suggest little or no effect on weight or BMI change in adults or children with overweight or obesity. Evidence for all the other interventions evaluated came mostly from single studies. The certainty of the included evidence varied from moderate to very low for the main outcomes (weight and BMI). All of the evaluated interventions would need further investigation to ascertain their strengths and limitations as effective strategies to change the behaviour of healthcare professionals or the organisation of care. As only two studies reported on cost, we know little about cost effectiveness across the evaluated interventions. What is the aim of this review? To assess the effectiveness of strategies to change the behaviour of health professionals and the organisation of care to promote weight reduction in people with overweight and obesity. This is an update of a Cochrane Review. Key messages We found little evidence for a clinically important intervention effect on weight loss, or on body mass index (BMI) change. The results suggest that a brief educational intervention provided to healthcare professionals may lead to a slight decrease in weight for their adult patients, but the results of the studies were not consistent. Evidence for all the other interventions we looked at came mostly from single studies, which is why these interventions need further investigation. What was studied in the review? The number of people with overweight or obesity is increasing around the world. Excessive weight is associated with many chronic diseases. We searched the literature for studies that evaluated the effects of interventions aimed at changing the behaviour of health professionals or the way care is organised for improved weight management and weight loss. What are the main results of this review? We included 12 studies, eight in adults and four in children. One hundred and thirty‐nine family practices were included, providing care to 89,754 people who were followed for 12 months. Seven studies evaluated the effects of various interventions directed at healthcare professionals (i.e. education, reminders, and decision support tools), and the other five evaluated different organisational interventions (i.e. changes in who delivers the health care, how and where it is delivered, etc.). The comparison intervention was standard care, or the opportunity to seek it. The main outcomes assessed were weight or weight change for adults, and how their weight compared with their peers for children. Professional interventions Brief education of primary care physicians in weight management may slightly decrease the weight of their patients, . Tailoring the education to the healthcare professional to improve how closely they follow guidelines probably led to little or no difference in obesity management or weight loss at study end. We are uncertain whether issuing doctors with printed reminders about weight management strategies helped to reduce their patients' weight, compared to standard care. Two studies reported that providing doctors with a clinical decision support tool within the practice may lead to little or no difference in the BMI of children with obesity or in the weight of adults with overweight or obesity, compared to patients receiving standard care. Organisational interventions Two studies assessed the effect of multidisciplinary teams. Weight‐loss programmes led by a dietitian or by a doctor plus a dietitian may lead to greater weight loss in adult patients than standard care. Shared care (between family practice and hospital doctors and dietitians) probably leads to little or no difference in the BMI of children with obesity, compared to standard care. Organisational restructuring of the delivery of family practice care (i.e. introducing the chronic care model: training of the whole practice team, enhanced electronic medical record system, the paediatric nurse practitioners playing a key role in delivering the intervention) led to a slightly lower increase in the BMI of children with obesity at intervention clinics, compared to standard care. Two studies assessed changes in the setting of service delivery. The use of both mail and phone interventions to promote weight loss probably led to little or no difference in weight loss of adults with overweight or obesity, compared to standard care. Family practice weight management programmes conducted by nurses may lead to little or no difference in BMI in children with obesity, as compared to specialist obesity hospital clinics run by consultants. How up‐to‐date is this review? The review authors searched for studies up to September 2016.

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          Most cited references 79

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          Educational outreach visits: effects on professional practice and health care outcomes.

           Mary O'Brien (corresponding) ,  Stephen Rogers,  Gro Jamtvedt (2007)
          Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting. To assess the effects of EOVs on health professional practice or patient outcomes. For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL. Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings. Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention. We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed. EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.
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            Ten things that motivational interviewing is not.

            In the 26 years since it was first introduced in this journal, motivational interviewing (MI) has become confused with various other ideas and approaches, owing in part to its rapid international diffusion. Based on confusions that have arisen in publications and presentations regarding MI, the authors compiled a list of 10 concepts and procedures with which MI should not be addled. This article discusses 10 things that MI is not: (1) the transtheoretical model of change; (2) a way of tricking people into doing what you want them to do; (3) a technique; (4) decisional balance; (5) assessment feedback; (6) cognitive-behavior therapy; (7) client-centered therapy; (8) easy to learn; (9) practice as usual; and (10) a panacea. Clarity about what does (and does not) constitute MI promotes quality assurance in scientific research, clinical practice, and training.
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              The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity

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                Author and article information

                Journal
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                November 30 2017
                Affiliations
                [1 ]Norwegian Institute of Public Health; Division for Health Services; Pilestredet Park 7 Oslo Norway 0176
                [2 ]University of Oxford; Nuffield Department of Population Health; Oxford UK
                [3 ]Queen's Campus, Durham University; School of Medicine, Pharmacy and Health, Wolfson Research Institute; University Boulevard Thornaby Stockton-on-Tees UK TS17 6BH
                Article
                10.1002/14651858.CD000984.pub3
                6486102
                29190418
                © 2017
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