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      What is the effectiveness of printed educational materials on primary care physician knowledge, behaviour, and patient outcomes: a systematic review and meta-analyses

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          Abstract

          Background

          Printed educational materials (PEMs) are commonly used simple interventions that can be used alone or with other interventions to disseminate clinical evidence. They have been shown to have a small effect on health professional behaviour. However, we do not know whether they are effective in primary care. We investigated whether PEMs improve primary care physician (PCP) knowledge, behaviour, and patient outcomes.

          Methods

          We conducted a systematic review of PEMs developed for PCPs. Electronic databases were searched for randomized controlled trials, quasi randomized controlled trials, controlled before and after studies, and interrupted time series. We combined studies using meta-analyses when possible. Statistical heterogeneity was examined, and meta-analysis was performed using a random effects model when significant statistical heterogeneity was present and a fixed effects model otherwise. The template for intervention description and replication (TIDieR) checklist was used to assess the quality of intervention description.

          Results

          Our search identified 12,439 studies and 40 studies met our inclusion criteria. We combined outcomes from 26 studies in eight meta-analyses. No significant effect was found on clinically important patient outcomes, physician behaviour, or physician cognition when PEMs were compared to usual care. In the 14 studies that could not be included in the meta-analyses, 14 of 71 outcomes were significantly improved following receipt of PEMs compared to usual care. Most studies lacked details needed to replicate the intervention.

          Conclusions

          PEMs were not effective at improving patient outcomes, knowledge, or behaviour of PCPs. Further trials should explore ways to optimize the intervention and provide detailed information on the design of the materials.

          Protocol registration

          PROSPERO, CRD42013004356

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13012-015-0347-5) contains supplementary material, which is available to authorized users.

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          Most cited references46

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          The assessment of clinical skills/competence/performance.

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            Changing provider behavior: an overview of systematic reviews of interventions.

            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. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. 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. 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.
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              Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.

              Poor interprofessional collaboration (IPC) can negatively affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. To assess the impact of practice-based interventions designed to change IPC, compared to no intervention or to an alternate intervention, on one or more of the following primary outcomes: patient satisfaction and/or the effectiveness and efficiency of the health care provided. Secondary outcomes include the degree of IPC achieved. We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2000-2007), MEDLINE (1950-2007) and CINAHL (1982-2007). We also handsearched the Journal of Interprofessional Care (1999 to 2007) and reference lists of the five included studies. Randomised controlled trials of practice-based IPC interventions that reported changes in objectively-measured or self-reported (by use of a validated instrument) patient/client outcomes and/or health status outcomes and/or healthcare process outcomes and/or measures of IPC. At least two of the three reviewers independently assessed the eligibility of each potentially relevant study. One author extracted data from and assessed risk of bias of included studies, consulting with the other authors when necessary. A meta-analysis of study outcomes was not possible given the small number of included studies and their heterogeneity in relation to clinical settings, interventions and outcome measures. Consequently, we summarised the study data and presented the results in a narrative format. Five studies met the inclusion criteria; two studies examined interprofessional rounds, two studies examined interprofessional meetings, and one study examined externally facilitated interprofessional audit. One study on daily interdisciplinary rounds in inpatient medical wards at an acute care hospital showed a positive impact on length of stay and total charges, but another study on daily interdisciplinary rounds in a community hospital telemetry ward found no impact on length of stay. Monthly multidisciplinary team meetings improved prescribing of psychotropic drugs in nursing homes. Videoconferencing compared to audioconferencing multidisciplinary case conferences showed mixed results; there was a decreased number of case conferences per patient and shorter length of treatment, but no differences in occasions of service or the length of the conference. There was also no difference between the groups in the number of communications between health professionals recorded in the notes. Multidisciplinary meetings with an external facilitator, who used strategies to encourage collaborative working, was associated with increased audit activity and reported improvements to care. In this updated review, we found five studies (four new studies) that met the inclusion criteria. The review suggests that practice-based IPC interventions can improve healthcare processes and outcomes, but due to the limitations in terms of the small number of studies, sample sizes, problems with conceptualising and measuring collaboration, and heterogeneity of interventions and settings, it is difficult to draw generalisable inferences about the key elements of IPC and its effectiveness. More rigorous, cluster randomised studies with an explicit focus on IPC and its measurement, are needed to provide better evidence of the impact of practice-based IPC interventions on professional practice and healthcare outcomes. These studies should include qualitative methods to provide insight into how the interventions affect collaboration and how improved collaboration contributes to changes in outcomes.
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                Author and article information

                Contributors
                a.grudniewicz@mail.utoronto.ca
                ryan.kealey@mail.utoronto.ca
                Reitze.Rodseth@kznhealth.gov.za
                jhamid@mcmaster.ca
                David.rudoler@utoronto.ca
                sharon.straus@utoronto.ca
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                1 December 2015
                1 December 2015
                2015
                : 10
                : 164
                Affiliations
                [ ]Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Canada
                [ ]Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, 7th Floor, East Building, Toronto, Canada
                [ ]Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, Bahen Centre for Information Technology, 40 St. George Street, Toronto, Canada
                [ ]Perioperative Research Group, Department of Anaesthetics, Grey’s Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Nata, Pietermaritzburg, South Africa
                [ ]Department of Outcomes Research, Cleveland Clinic, Cleveland, OH USA
                [ ]Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
                Article
                347
                10.1186/s13012-015-0347-5
                4666153
                26626547
                d3711fee-76e1-4bd7-9631-158d14ef1439
                © Grudniewicz et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 8 September 2015
                : 29 October 2015
                Categories
                Systematic Review
                Custom metadata
                © The Author(s) 2015

                Medicine
                primary care,evidence-based medicine,printed educational materials
                Medicine
                primary care, evidence-based medicine, printed educational materials

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