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Changing Clinical Practice: Educational outreach visits lead to positive changes in health professional behaviour
Lead author's name and fax: m O'Brien, cancer care Research Unit, Hamilton Regional Cancer Centre, Ontario. maryann.o'brien@hrcc.on.ca
Three-part Clinical Question: Are education outreach visits effective in improving the practice of health care providers or health care outcomes? Search Terms: In Cochrane Database of Systematic Reviews: change practice.mp (26)
The Review: Data Sources: : Cochrane Library, Medline, non-English sources, Reference lists
Study Selection: RCTs of outreach visits: Participants: - health care providers.
Intervention: Outreach - use of a trained person who meets with providers in their practice settings to provide information with the intention of changing practice. Outcome measures -objectively measured health care provider performance or health care outcomes. Excluded: students.
Data Extraction: Used standard method of EPOC group: practice location, recruitment, targeted behaviours, randomisation, allocation concealment, intervention, outcome, follow up. The studies were multiple independent reviews of individual reports. They were not tested for heterogeneity.
The Evidence: 18 studies (involving > 1800 doctors). All outreach interventions had several components. Reminders or audit and feedback complemented some visits. Educational outreach defined as " a personal visit by a trained person to a health care provider in his or her own setting". 13 studies - targeted behaviours - prescribing practices; 3 studies - targeted behaviours - preventive services; and 2 studies directed toward improving management of common problems encountered in general practice. All studies examined physician behaviour and 3 studies other health professionals such as nurses, nursing home attendants or health care workers were targeted.
Positive effects on practice were observed in all studies. Outreach visits (inc educational materials or conferences) are more effective than no intervention – 3 trials - all effective in reducing inappropriate prescribing (24%to 50% relative improvement). Outreach visits combined with other complementary interventions including reminders, audit and feedback, use of local opinion leaders, marketing strategies or patient-mediated interventions are more effective than no intervention. In 12 of 13 trials of combined interventions, there were positive effects in favour of the intervention group (15-68% relative improvement)
Comments: 1) Do the methods allow accurate testing of the hypothesis? - YES 2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? - YES - Methodologically sound systematic review. 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 - need an estimate of the cost effectiveness of educational outreach. Further research also to determine how the effects persist over time. Need cost-effectiveness analysis too. 6) Did they make any recommendations based on the results and were they appropriate? - YES - Educational outreach visits combined with additional interventions are effective at reducing inappropriate prescribing – lead to changes in practice. Positive effects in all studies reviewed. Effects are small to moderate, but potentially of practical importance. 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? A 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? One study showed outreach to be better than audit and feedback 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 ; 08 December 2003
Email: md23s@udcf.gla.ac.uk
© SICS EBM Group 2004
Educational Outreach |
