August, 2016 - SUPPORT Summary of a systematic review | print this article |

Are tailored strategies effective for changing healthcare professional practice?

Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers. Change may be more likely if implementation strategies are specifically chosen to address potential obstacles. It is logical that strategies tailored to overcome identified barriers should be more effective than non-tailored ones.


Key messages

  •  Interventions tailored to address identified barriers are probably more likely to improve professional practice than no intervention or the dissemination of guidelines alone.
  •  It is uncertain whether tailored interventions are more likely to improve professional practice than non-tailored interventions.
  • Little is not known about how best to identify barriers to improving professional practice and how to tailor interventions to address these barriers.

Background

Strategies to disseminate and implement change in the performance of healthcare professionals have had variable impacts. The level of effectiveness has varied not only between different strategies, but also when the same strategy has been used on different occasions.

Tailored implementation strategies require the identification of important barriers to change and the selection of implementation strategies most likely to be effective in addressing them. Tailoring strategies might help to maximise their potential impact. There are a variety of ways to identify barriers and to select ways to address them. Methods to identify barries include: making informal judgements, brainstorming, surveys, interviews, focus groups and observations. Methods to select ways to address identified barriers include theory-based approaches and experimental modeling of potential interventions.



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes
Type of What the review authors searched for What the review authors found
Study designs & interventions

Randomized trials of interventions tailored to address prospectively identified barriers to change.

Studies had to involve a comparison group that did not receive a tailored intervention or a comparison between an intervention that was targeted at both individual and social or organisational barriers, compared with an intervention targeted at only individual barriers.

Thirty-two randomized trials. Interventions assessed were varied and included (among others): printed materials; educational outreach; clinical guidelines; audit and feedback; interactive workshops; teaching sessions/discussions of patients; facilitation/practice meetings; and individual/group academic detailing.

Participants

Healthcare professionals responsible for patient care.

Primarily physicians (14 studies), mixed professional groups (8), nurses (4); pharmacists (2), geriatric teams (1), gynaecology teams (1), and physicians (1).

Settings

Any setting

Primary care or community settings (17 studies), hospital settings (7), nursing homes (3), and one each in child health clinics, community pharmacies, a regional health system, and a Medicaid program. The studies were conducted in the United States of America (USA) (12), the Netherlands (5), the United Kingdom (UK) (4), Belgium (2), Indonesia (2), Norway (2), South Africa (2), and Canada (1), Ireland (1), and Portugal (1).

Outcomes

Objectively measured professional performance (excluding self-reporting) or patient outcomes in a healthcare setting or both.

Change in prescribing behaviour (12 studies), management of a disease (including diagnosis, assessment and treatment) (11), preventive care (6), influenza vaccination (2), reporting adverse drug reactions (1).

Date of most recent search: December 2014
Limitations: This is a well-conducted systematic review with only minor limitations.

Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to address determinants of practice. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470.

 

Summary of findings

The review included 32 studies. The studies used a variety of methods to identify barriers, including face-to-face interviews, focus groups with physicians or patients, surveys, workshop discussions, telephone interviews, literature reviews or brainstorming by opinion leaders.

The participants in the studies were mostly physicians and nurses. The interventions included the distribution of printed materials, educational outreach, workshop activities, small discussion groups, auditing and feedback. Most of the interventions were targeted at changing prescribing behaviour.

 

1) Tailored interventions compared to no intervention or guidelines alone

Mixed results were found both across and within the included studies. There was variation in the reporting of how barriers had influenced the design of the intervention. The selection of interventions often relied on the judgements of the investigators and was not informed by explicit theories of behavioural or organisational change.

Seventeen studies compared a tailored intervention to no intervention, of which it was possible to include seven in the main analysis. Fifteen studies compared a tailored intervention to a non-tailored intervention, of which it was possible to include eight in the main analysis. In all but one of the eight trials, the non-tailored intervention consisted of the dissemination of written educational materials or guidelines.

The odds ratio ranged from 1.08 to 10.59 for the 15 studies included in the main analysis. The 17 studies not included in the main analysis had findings showing variable effectiveness consistent with the studies included in the main analysis. The combined (average) odds ratio for these 15 studies was 1.56 (95% CI: 1.27 to 1.93), in favour of tailored interventions. In a situation where adherence with recommended practice was initially 60% this would correspond to an improvement to 70%. In a situation where adherence was initially 20% this would correspond to an improvement to 28%.

The authors investigated the following possible causes of variability in the effect of tailored interventions across the 15 studies: the type of control group (no intervention versus dissemination of written educational materials or guidelines), the risk of bias, explicit utilisation of a theory to select the interventions, adjustment to local factors, and the number of domains addressed by the determinants identified.

None of these were found to be associated with the reported effectiveness of the tailored interventions.

  • Tailored interventions probably improve professional practice compared to no intervention or the dissemination of guidelines alone. The certainty of this evidence is moderate.
  • It is uncertain whether tailored interventions are more likely to improve professional practice than non-tailored interventions.

Tailored interventions compared to no intervention or guidelines alone

People: Healthcare professionals responsible for patient care
Settings
: High income countries
Intervention
: Tailored interventions to implement practice guidelines
Comparison
: No intervention or dissemination of guidelines alone

Outcomes

Absolute effect

Relative effect (95% CI)

Certainty of the evidence (GRADE)

Without tailored intervention

With tailored intervention

Difference (Margin of error)

Desired professional practice (adherence to guideline recommendations)

 Moderate adherence* 60 per 100 patients

 70 per 100 patients

OR 1.56 (1.27 to 1.93)

Moderate

Difference: 10 more patients receiving recommended practice per 100 patient encounters (Margin of error: 6 to 14 more patients)



Low adherence* 20 per 100 patients

 

Difference: 8 more patients receiving recommended practice per 100 patient encounters (Margin of error: 4 to 13 more patients)

Margin of error = Confidence Interval (95% CI) OR: Odds Ratio

GRADE: GRADE Working Group grades of evidence (see above and last page)

* The assumed adherence WITHOUT the tailored intervention was selected to aid interpretation of the overall odds ratios in situations in which there was low adherence (20% desired practice) and moderate adherence (60% desired practice). The corresponding adherence WITH the intervention (and the 95% confidence interval for the difference) is based on the overall odds ratio (and its 95% confidence interval).

† The OR and confidence intervals shown are taken from a meta-regression. The results of 14 studies not included in the meta-regression indicated that, on average, tailored interventions improve professional practice. However, the effects were mixed.

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

Interventions tailored to barriers identified prospectively are more likely to improve professional practice than no intervention or the dissemination of guidelines or educational materials alone.

  • The barriers to changing heath professional behaviour vary across and within health systems. This may limit the transferability of findings from one specific healthcare setting to other settings. However, tailored interventions are likely to be effective compared to no intervention or the dissemination of guidelines across health systems. The uncertainty about how best to identify barriers and tailor interventions to address them is also transferable.
EQUITY

The systematic review did not address equity issues.

  • Tailored interventions might be more difficult to design and implement for disadvantaged populations due to a lack of available resources. In addition, there may be a greater need to address social or organisational barriers caused by inadequate infrastructure. Consequently, designing and implementing effective, tailored interventions for disadvantaged populations might require additional resources and technical support.
ECONOMIC CONSIDERATIONS

The review did not find evidence of the cost-effectiveness of tailored interventions or of the effectiveness of alternative methods of tailoring interventions.

  • It is reasonable to use low-cost methods to tailor interventions, particularly in low-resource settings, given the lack of evidence on the effectiveness of more expensive methods of tailoring interventions.
  • Some implementation strategies (e.g. reminders and audit and feedback) may be costly in low-income settings. The benefit of using implementation strategies that are costly, including tailored interventions, needs to be balanced against the potential benefits, which remain uncertain.
MONITORING & EVALUATION

At present, there is no single, standard method for tailoring strategies to address identified barriers. Based on the available evidence, it is not possible to decide which approach is most effective. The relative costs of different approaches are also unclear.

  • Given the uncertainty about the costs and effectiveness of tailored interventions, and of implementation strategies in general, monitoring and evaluation should be done routinely when introducing tailored interventions to improve professional practice. More research is needed to evaluate the different methods to address barriers.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

Additional information

Related literature

Fretheim A, Munabi-Babigumira S, Oxman AD, et al. SUPPORT Tools for Evidence-informed policymaking in health 6: Using research evidence to address how an option will be implemented. Health Res Policy Syst 2009; 7 Suppl 1:S6.

 

Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation science 2013; 8:35.

 

Krause J, Van Lieshout J, Klomp R, et al. Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods. Implementation science 2014; 9:102.

 

Huntink E, Lieshout J van, Aakhus E, et al. Stakeholders' contributions to tailored implementation programs: an observational study of group interview methods. Implementation Science 2014; 9:185.

 

Wensing M, Huntink E, van Lieshout J, et al. Tailored implementation of evidence-based practice for patients with chronic diseases. PloS One 2014; 9(7):e101981.

 

This summary was prepared by

Sebastián García Martí and Agustín Ciapponi, Argentine Cochrane Centre IECS -Institute for Clinical Effectiveness and Health Policy- Iberoamerican Cochrane Network, Argentina.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Tomas Pantoja and Richard Baker.

 

This review should be cited as

Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki-Cwirko M, van Lieshout J, Jäger C.

Tailored interventions to address determinants of practice.

Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470.

 

The summary should be cited as

García Martí S, Ciapponi A. Are tailored strategies effective for changing healthcare professional practice? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

 

Keywords

All Summaries: evidence-informed health policy, evidence-based, systematic re-view, health systems research, healthcare, low- and middle-income countries, developing countries, primary healthcare

tailored interventions, implementation strategies, professional practice

 



Comments