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

Does practice facilitation in primary care settings improve adoption of evidence-based guidelines?

Practice facilitation is a multifaceted approach whereby skilled individuals, either internal or external to a setting, are used to promote adoption and use of evidence-based guidelines within the setting (practice).

 

Key messages

  •  The use of practice facilitation as a multifaceted approach probably improves the adoption of evidence-based guidelines in primary care settings.
  •  All studies of the effects of practice facilitation were conducted in high-income countries.

-Further research is needed to determine the effectiveness and cost implications of practice facilitation in low-income countries.

Background

Adoption of evidence-based guidelines is a challenge in many primary care settings because availability of knowledge alone is often insufficient to change practice. Lecture-based educative strategies to disseminate evidence-based guidelines are often ineffective, while multifaceted interventions such as interactive education and reminders may be more effective. Practice facilitation is a multifaceted approach that uses internal or external individuals to encourage evidence-based practice.



About the systematic review underlying this summary

Review objectivesTo undertake a quantitative synthesis of the effect of practice facilitation on evidence-based practice behaviour

Type of What the review authors searched for What the review authors found

Study designs & interventions

Randomized and non-randomized trials and prospective studies of individual practice facilitation

23 studies of practice facilitation interventions (17 randomized trials, three cluster randomized trials, and three non-randomized studies)

Participants

All healthcare providers in primary care practices

All healthcare providers in primary care practices

Settings

Primary care settings

Primary care practices in the USA (12 studies), the Netherlands (5), Canada (3), the UK (2) and Australia (1)

Outcomes

Change in evidence-based practice behaviour

Studies reported this outcome in varied ways, such as increased screening or management of different conditions and improvements in care provided

Date of most recent search: December 2010

Limitations: This is a well-conducted systematic review. However, the literature searches were restricted to English-language studies.

Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74.

 

Summary of findings

The review found 23 studies conducted in high-income countries that evaluated the use of practice facilitation to improve adoption of evidence-based guidelines. About half of the studies in the review used registered nurses or masters’ educated individuals with training as practice facilitators. Most of the studies focused primarily on preventive care.

A key component in all the studies was audit with feedback. Most studies also included interactive consensus building and goal setting, and many incorporated collaborative meetings, either face to face or virtual. The intensity of the interventions varied (from two meetings each 0.25 hrs to 18 meetings each six hours), as did the duration (two to 26 months).

Increased intensity, fewer practices per facilitator, and whether the intervention was tailored to fit the needs of the pratice, were all associated with stronger effects.


Practice facilitation for improving adoption of evidence-based guidelines in primary care settings.

23 studies conducted in primary care settings in high-income countries measured the mean change in target behavior as a result of the intervention.

  • Practice facilitation probably improves the adoption of evidence-based guidelines in primary care settings. The certainty of this evidence is moderate.

Practice facilitation for adoption of evidence-based guidelines

People: Healthcare providers in primary care practices
Settings
: High-income countries
Intervention
: Practice facilitation
Comparison
: No practice facilitation
Outcomes

Absolute effect

Relative effect (95% CI) Certainty of the evidence (GRADE)

Without practice facilitation

With practice facilitation

Difference (Margin of error)

Desired professional practice (adherence to guideline recommendations)

Moderate adherence* 60 per 100

81 per 100

OR 2.76 (2.18 to 3.43)†

Moderate


Difference: 21 more patients receiving recommended practice per 100 patient encounters (Margin of error: 17 to 24 more)



Low adherence* 20 per 100

41 per 100

Difference: 21 more patients receiving recommended practice per 100 patient encounters (Margin of error: 15 to 26 more)

Margin of error = Confidence interval (95% CI) OR: Odds ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

* For the SUPPORT-summary we selected two levels of baseline adherence to desired practice to help interpret the overall odds ratio (and its 95% confidence interval). Moderate adherence was assumed at 60% of desired practice while low adherence was assumed at 20% of desired practice.

† The OR and confidence intervals are from a meta-analysis using standardized mean differences (SMD), converted to an odds ratio by the review authors (SMD=0.56, 95% CI 0.43 to 0.68).

‡ The certainty of the evidence is moderate because of study limitations (risk of bias) in some of the included studies and heterogeneity of results.

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

The review did not include any studies conducted in low-income countries that evaluated the use of practice facilitation to promote adoption of evidence-based guidelines.

  • Practice facilitation might be difficult to implement in low-resource settings, particularly the audit and feedback component, and it might be more difficult to make necessary organisational changes such as implementation of quality improvement tools.
EQUITY

The studies identified by the review did not address the issue of equity.

  • Poor adherence to evidence-based guidelines often impacts more on disadvantaged populations. Practice facilitation as a strategy to improve evidence-based guideline adoption could help these populations achieve the benefits of better quality service. However, practice facilitation might be more difficult to implement in disadvantaged settings.
ECONOMIC CONSIDERATIONS

The studies included in the review did not provide any data on the costs of practice facilitation as an intervention.

  • It is not possible to estimate the cost-effectiveness of practice facilitation based on the available information.
MONITORING & EVALUATION

The review did not find any evidence of the effect of practice facilitation in low-income countries and did not report any findings of the cost-effectiveness.

  • If practice facilitation is used in low-income countries, its effects and cost-effectiveness should be evaluated, preferrably in (cluster) randomised trials.

*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

Nagykaldi Z, Mold JW, Aspy CB. Practice facilitators: a review of the literature. Fam Med. 2005;37(8):581-588.

 

Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/index.html

 

 

O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, Issue 4.

 

This summary was prepared by

Michael Gathu, KEMRI-Wellcome Trust Research Programme, Kenya

 

Conflict of interest

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

 

Acknowledgements

This summary has been peer reviewed by: Mike English, Mary Ann O'brien, Bruce Baskerville, and Atle Fretheim

 

This review should be cited as

Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74.

 

The summary should be cited as

Gathu M. Does practice facilitation in primary care settings improve adoption of evidence-based guidelines? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

 

Keywords

All Summaries:

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care practice facilitation, quality improvement, primary care, audit, feedback, guideline adoption, guideline adherence.



Comments