Summary of the effects of single strategies and multifaceted strategies on adherence to desired practice
| Strategy | Benchmark review Author, year (reference) | Outcome | Benchmark review results—single strategy alone vs no strategy | Benchmark review—details | Benchmark review —overall conclusion | Benchmark review—other comparisons | Benchmark reviews vs other (non-benchmark) reviews Overall results consistent with other relevant reviews*? |
|---|---|---|---|---|---|---|---|
| Professional-level strategies | |||||||
| A&F | Ivers et al, 201234 | Compliance with desired practice | D*†: median absolute RD‡§=3% (IQR 1.8–7.7%) | 26 RCTs (661 clusters/groups of health providers and 605 health professions); low-moderate risk of bias | Small (range: small to modest) | A&F with or without other strategies vs no strategy: D†: median RD‡§=4.3% (IQR 0.5–16.0%) (49 RCTs) | Yes13 16–33 |
| C†: median percentage change relative to baseline control‡=1.3% (IQR 1.3–11%) | 13 RCTs; low-moderate risk of bias | Not applicable | A&F with or without other strategies vs no strategy: median percentage change relative to baseline control‡=1.3% (IQR 1.3–28.9%) (21 RCTs) | ||||
| Physician reminder | Shojania et al, 200976 Computer reminder (delivered at the point of care) | Improvement in process adherence | D*†: median RD¶=5.7% (IQR 2.0–24%) | 18 RCT/quasi-randomised design | Modest (range: small to large) | Computer reminders with other strategies vs other strategies alone: D†: median RD¶=1.9% (IQR 0.0–6.2%; n trials not reported) | Yes13 19 21 22 25 28 29 37 40 49 58 60 66–75 77 |
| C†: not reported | Not applicable | C†: not reported | |||||
| EOV | O'Brien et al, 200750 | Professional practice | D*†: median RD§¶=5% (IQR 3–6.2%) | 19 RCT; low-moderate risk of bias | Small (range: small to modest) | EOV with or without other strategies vs no strategy: D†: median RD§¶=5.6% (IQR 3–9%; 28 RCTs) | Yes13 21 22 26–28 32 35 37 40 45–49 |
| C†: median adjusted change=23% (IQR 12–39%) | 15 RCTs; low-moderate risk of bias | Not applicable | C†: median adjusted change=21% (IQR 11 to 41%; 17 RCTs) | ||||
| Educational meetings and workshops (including continuing medical education) | Forsetlund et al, 200912 | Compliance with desired practice | D*†: Median RD‡§=6% (IQR 2.9–15.3%) | 19 RCTs; low-moderate risk of bias | Modest (range: small to moderate) | Educational meetings with or without other strategies vs no strategy: D†: median RD‡§=6% (IQR 1.8–15.9%) (30 RCTs) | Yes19 21 22 25 31 32 35 38 41 42 47 51–64 |
| C†: median adjusted % change relative to the control group 10% (IQR 8–32%) | 5 RCTs | Not applicable | C†: median adjusted % change relative to the control group 10% (IQR 9–24%) (8 RCTs) | ||||
| Local opinion leaders | Flodgren et al, 2011a65 | Compliance with desired practice | D*†: median RD¶§=9% (IQR −15 to +38%) | 5 RCT; high risk of bias | Modest and variable (range from negative, no effect, to small and large effects) Unclear due to inconsistent and limited evidence | Local opinion leaders alone or together with other strategies vs no intervention or other strategies alone D†: median RD¶§=12% (IQR 6–14.5%; 15 RCTs) | Mostly consistent: mixed effects21 22 24 32 37 40 |
| C†: not reported | C†: not reported | ||||||
| Printed educational materials (majority studies disseminated passively) | Giguère et al, 201244 | Professional practice | D*†: median RD¶=2% (IQR −0.6 to 29%) | 7 studies; low quality | Small and variable (range: negative, no effect, to small and large effects) | Mixed but mostly consistent13 21–24 26 27 32 35–43 | |
| C†: SMD 13% (IQR 16–196%) | 3 studies; low or very low quality | ||||||
| Organisational-level strategies | |||||||
| Revising professional roles | No benchmark review identified | 28 61 69 78 83 84 | |||||
| Facilitation | Baskerville et al, 201282 | Compliance with desired practice | SMD†=0.56 (95% CI 0.43 to 0.68; z=8.76; p<0.001; I2=20%) OR=2.76 (95% CI 2.18 to 3.43; non-significant heterogeneity, p=0.19) | 20 RCTs and 3 CCTs (1398 participants); high quality | Effective (consistent) | Not applicable | Yes78–81 |
| Context-level strategies | |||||||
| Financial strategies | Scott et al, 201191 | Professional behaviours | All types of financial incentives, provided by primary care physicians Uncertain (no combined/overall effect size) Authors’ conclusion: different financial interventions had positive but modest and variable effects on a small number of outcome measures of quality of healthcare (7 studies) | 7 studies | Variable High uncertainty | Not applicable | Yes. Some subsequent reviews presented positive results and some showed no effect or mixed results20 23 78 80 85–90 |
| Regulatory strategies | None identified | Not applicable | Not applicable | Not applicable | |||
| Others | |||||||
| Multifaceted strategies | No benchmark review identified | Multifaceted strategies likely to be more effective27 32 36 48 51 52 60 61 71 78 105–113 Multifaceted less or just as effective/unclear12 13 17 19 20 34 50 65 76 104 | |||||
| Tailored strategies to identified barriers | Baker et al, 201092 | Compliance with desired practice | Pooled adjusted OR†=1.54 (95% CI 1.16 to 2.01) from the Bayesian analysis Pooled OR=1.52 (95% CI 1.27 to 1.82) p<0.001 from the classical analysis | 12 RCTs (2189 participants; moderate quality) | Not applicable | Not applicable | No other review identified |
*Based on dichotomous data (intervention vs no intervention) from the benchmark review. Overall effect is described using the definition proposed by Grimshaw et al13 (see Methods).
†D, dichotomous; C, continuous; SMD, standardised mean difference.
‡Weighed according to the number of health professionals (number of practices, hospitals, communities) participating in the study.
§Adjusted for baseline differences in the outcome.
¶Unweighted or unclear weighting/adjustment.
A&F, Audit and feedback; CCT, controlled clinical trials; EOV, educational outreach visits; OR, odds ratio; RCT, randomised controlled trial; RD, risk difference.