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Changing Clinical Practice: Printed educational materials have small effects of uncertain importance
Lead author's name and fax: N Freemantle, Department of Primary Care and General Practice, University of Birmingham
Three-part Clinical Question: Are printed educational materials effective in improving professional practice and health care outcomes?
Search Terms: In Cochrane Database of Systematic Reviews: change practice.mp (26)
The Review: Data Sources: Cochrane Library, Medline, Embase, hand search, EPOC register of relevant trials, and contacted content area experts
Study Selection: RCTs assessing impact of printed educational materials against no intervention, and additional intervention plus printed educational materials against printed educational materials alone. Outcomes: any objective measure of professional performance, or patient health outcomes. Excluded studies examining: knowledge; attitudes; or satisfaction.
Data Extraction: Randomisation, intervention, concealment of allocation, follow-up, healthcare providers, blinding, and outcome measurement. The studies were multiple independent reviews of individual reports. They were not tested for heterogeneity.
The Evidence: 11 studies found in total - contained different types of comparisons: 9 studies: printed educational materials versus a non-intervention control - estimates in benefits to healthcare provider outcomes varied from -3% to 243% i.e. includes no effect, and for benefits to patient outcomes from -16% to 175% i.e. includes no effect. The practical effect of these changes was small at best. 6 studies: printed educational materials plus additional implementation strategies versus printed educational materials alone. Additional implementation strategy varied: educational outreach, use of local opinion leaders, and audit and feedback. Largest and perhaps most important effects was with addition of local opinion leaders - but only a small sample - we cannot give too much weight to this. No studies in ICU setting.
Comments: 1) Do the methods allow accurate testing of the hypothesis? - YES - Methodologically sound systematic review. 2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? - YES - The correct tests were done, however, limited number of studies and poor reporting of end-points prevent a quantitative summary of effects. 3) Are conclusions valid in light of the results? - YES 4) Did results get omitted, and why? - NO 5) Did they suggest areas of further research? YES - there is a big and urgent need in this area - given that printed educational materials are a commonly used method. Further research required: high quality RCTs: comparing printed educational materials against no intervention; and other RCTs of printed educational materials against alternative interventions. Need assessment of cost-effectiveness of printed educational materials. 6) Did they make any recommendations based on the results and were they appropriate? - YES - The body of evidence to support use of printed educational materials is small and the effects appear variable. The addition of educational outreach or local opinion leaders produces larger effects that may be important. 7) Is the study relevant to my clinical practice? YES - Provision of consistently good healthcare that continuously improves is our aim. We need to know what helps make changes to practice. 8) What level of evidence does this study represent? 1- 9) What grade of recommendation can I make on this result alone? B 10) What grade of recommendation can I make when this study is considered along with other available evidence? No additional evidence to be added. 11) Should I change my practice because of these results? NO - Simply providing written information may not lead to changes in practice - but quality and quantity limits certainty. 12) Should I audit my current practice because of these results? No, use this series of systematic reviews to decide what strategies will help you make changes to your practice. Then audit effects: remember to consider how to accurately record baseline activity.
Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary 01 December 2003 Email: md23s@udcf.gla.ac.uk
Kill or Update By: December 2009
© SICS EBM Group 2004 |
