SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
January, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Clinical decision making is often not based on the best available evidence. Reasons for this vary, and may be related to factors within the healthcare setting, patients, or health practitioners. Interventions have been designed to encourage the use of systematic reviews in making clinical decisions as one way of improving clinical decision making.
Perrier L, Mrklas K, Shepperd S, et al. Interventions encouraging the use of systematic reviews in clinical decision making: a systematic review. J Gen Intern Med 2011; 26:419-26.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Multifaceted and simple interventions - including components such as educational visits by experts, workshops and other types of training, reminders, audit and feedback, and provision of resources - have been evaluated to determine their effectiveness for improving clinical decision making. These interventions have been targeted at different audiences with different outcome measures in different settings.
| Review objectives: To assess the effectiveness of interventions for seeking, appraising, and applying evidence from systematic reviews in clinical decisions. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Quantitative studies using any intervention to encourage use of systematic reviews in clinical decision making |
Five randomised trials that examined strategies ranging from multifaceted to simple interventions. |
| Participants | Healthcare practitioners of any specialty involved in providing patient care. | Physicians (4 studies) one each in Canada, Thailand, UK, and Uruguay; Midwives (3 studies) one each in Thailand, UK, and Uruguay; Residents (1 study Uruguay); Interns (1 study Thailand); Students (1 study Thailand); Dentists (1 study Scotland) |
| Settings | All settings |
Primary care (1 study), hospitals (3 studies), dental practice (1 study) |
| Outcomes | Change in professional performance (prescribing patterns, use of diagnostic tests), health outcomes for patients (return visits, adverse events, length of stay, decrease in admissions), and measures of health care provider satisfaction, knowledge, or attitude. |
All five studies provided objective performance measures. Patient health outcome measures and measures of healthcare provider satisfaction were not reported in any study. |
| Date of most recent search: July 2009 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Perrier L, Mrklas K, Shepperd S, et al. Interventions encouraging the use of systematic reviews in clinical decision making: a systematic review. J Gen Intern Med 2011; 26:419-26.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
This review includes five studies all conducted in middle and high income countries. All five trials reported some form of professional performance measure. Reported outcome measures varied and included measures of preventive performance, up to datedness of practice, prescription patterns, uptake of recommended practices, and other measures.
One study in 40 hospitals in Thailand and Mexico reported a measure of healthcare provider satisfaction, which was their awareness and use of the WHO Reproductive Health Library. This multifaceted intervention included organizational buy in, use of facilitators, provision of print materials, and interactive workshops on using the WHO Reproductive Health Library.
Interventions for encouraging use of systematic reviews in clinical decision making |
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| People: All healthcare practitioners providing care to patients. Settings: Hospitals, primary care and other healthcare settings. Intervention: Multifaceted or simple interventions (such as workshops, use of facilitators and provision of materials). Comparison: No intervention. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| Changes in physician performance |
It is uncertain whether interventions geared towards encouraging use of systematic reviews in clinical decision making lead to positive changes in physician performance. |
Very low |
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| Interventions may improve awareness and use of libraries to search for systematic reviews. |
Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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All studies included in the review were conducted in middle and high income countries.
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The applicability of these findings to low income countries is uncertain.
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| EQUITY | |
| The included studies did not report data regarding differential effects of the interventions across different population groups. |
Interventions that are effective could reduce health inequity if targeted at disadvantaged settings, as a result of providing better quality of care to disadvantaged populations. Conversely, they could increase inequity if targeted at both more and less advantaged settings, if they were more acceptable and easier to integrate into healthcare systems in more advantaged settings. |
| ECONOMIC CONSIDERATIONS | |
| None of the included studies assessed costs associated with the interventions. |
The cost and cost effectiveness of these interventions are uncertain.
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| MONITORING & EVALUATION | |
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The review found that some interventions lead to positive changes but they did not adequately measure patient and practitioner performance outcomes.
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Rigorous impact evaluations of these strategies should be considered before scaling up their use.
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*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 |
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Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005; 4: CD003539.
Michael Gathu, KEMRI Wellcome Trust Research Programme, Kenya.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Laure Perrier and Airton Stein.
Perrier L, Mrklas K, Shepperd S, et al. Interventions encouraging the use of sys-tematic reviews in clinical decision-making: a systematic review. J Gen Intern Med 2011; 26:419-26.
Gathu M. What are the effects of interventions to encourage the use of systematic reviews in clinical decision-making? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care
KEMRI Wellcome Trust Research Programme, Nairobi, Kenya.
