Dataset Information

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews.

ABSTRACT:

Background

This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.

Design

This study is a systematic review of reviews.

Methods

MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.

Results

Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term "cause" or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed "causes" in terms of "barriers and facilitators" to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders' buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the "fit" between the intervention and the context is critical in determining the success of implementation.

Conclusions

This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.

Systematic review registration

PROSPERO CRD42014009410.

SUBMITTER: Lau R

PROVIDER: S-EPMC4802575 | biostudies-literature | 2016 Mar

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews.

Lau Rosa R Stevenson Fiona F Ong Bie Nio BN Dziedzic Krysia K Treweek Shaun S Eldridge Sandra S Everitt Hazel H Kennedy Anne A Qureshi Nadeem N Rogers Anne A Peacock Richard R Murray Elizabeth E

Implementation science : IS 20160322

<h4>Background</h4>This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.<h4>Design</h4>This study is a systematic review of reviews.<h4>Methods</h4>MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted an ...[more]

PMID: 27001107

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Project description:BackgroundIn contemporary medical research, randomised controlled trials are seen as the gold standard for establishing treatment effects where it is ethical and practical to conduct them. In palliative care such trials are often impractical, unethical, or extremely difficult, with multiple methodological problems. We review the utility of Cochrane reviews in informing palliative care practice.MethodsPublished reviews in palliative care registered with the Cochrane Pain, Palliative and Supportive Care Group as of December 2007 were obtained from the Cochrane Database of Systematic Reviews, issue 1, 2008. We reviewed the quality and quantity of primary studies available for each review, assessed the quality of the review process, and judged the strength of the evidence presented. There was no prior intention to perform any statistical analyses.Results25 published systematic reviews were identified. Numbers of included trials ranged from none to 54. Within each review, included trials were heterogeneous with respect to patients, interventions, and outcomes, and the number of patients contributing to any single analysis was generally much lower than the total included in the review. A variety of tools were used to assess trial quality; seven reviews did not use this information to exclude low quality studies, weight analyses, or perform sensitivity analysis for effect of low quality. Authors indicated that there were frequently major problems with the primary studies, individually or in aggregate. Our judgment was that the reviewing process was generally good in these reviews, and that conclusions were limited by the number, size, quality and validity of the primary studies.We judged the evidence about 23 of the 25 interventions to be weak. Two reviews had stronger evidence, but with limitations due to methodological heterogeneity or definition of outcomes. No review provided strong evidence of no effect.ConclusionCochrane reviews in palliative care are well performed, but fail to provide good evidence for clinical practice because the primary studies are few in number, small, clinically heterogeneous, and of poor quality and external validity. They are useful in highlighting the weakness of the evidence base and problems in performing trials in palliative care.

Project description:There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.Study design: overview of reviews.MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

Project description:BackgroundAs a first step in developing a framework to evaluate and improve the quality of care of children in primary care there is a need to identify the evidence base underpinning interventions relevant to child health. Our objective was to identify all Cochrane systematic reviews relevant to the management of childhood conditions in primary care and to assess the extent to which Cochrane reviews reflect the burden of childhood illness presenting in primary care.Methodology/principal findingsWe used the Cochrane Child Health Field register of child-relevant systematic reviews to complete an overview of Cochrane reviews related to the management of children in primary care. We compared the proportion of systematic reviews with the proportion of consultations in Australia, US, Dutch and UK general practice in children. We identified 396 relevant systematic reviews; 358 included primary studies on children while 251 undertook a meta-analysis. Most reviews (n = 218, 55%) focused on chronic conditions and over half (n = 216, 57%) evaluated drug interventions. Since 2000, the percentage of pediatric primary care relevant reviews only increased by 2% (7% to 9%) compared to 18% (10% to 28%) in all child relevant reviews. Almost a quarter of reviews (n = 78, 23%) were published on asthma treatments which only account for 3-5% of consultations. Conversely, 15-23% of consultations are due to skin conditions yet they represent only 7% (n = 23) of reviews.Conclusions/significanceAlthough Cochrane systematic reviews focus on clinical trials and do not provide a comprehensive picture of the evidence base underpinning the management of children in primary care, the mismatch between the focus of the published research and the focus of clinical activity is striking. Clinical trials are an important component of the evidence base and the lack of trial evidence to demonstrate intervention effectiveness in substantial areas of primary care for children should be addressed.

Project description:BackgroundAntidepressants (ADs) are commonly prescribed in primary care and are mostly indicated for depression. According to the literature, they are now more frequently prescribed for health conditions other than psychiatric ones. Due to their many indications in a wide range of medical fields, assessing the appropriateness of AD prescription seems to be a challenge for GPs. The aim of this study was to review evidence from guidelines for antidepressant prescription for non-psychiatric conditions in Primary Care (PC) settings.MethodsData were retrieved from French, English and US guideline databases. Guidelines or reviews were eligible if keywords regarding 44 non-psychiatric conditions related to GPs' prescription of ADs were encountered. After excluding psychiatric and non-primary care conditions, the guidelines were checked for keywords related to AD use. The latest updated version of the guidelines was kept. Recent data was searched in the Cochrane Database of Systematic Reviews and in PubMed for updated reviews and randomized control trials (RCTs).ResultsSeventy-eight documents were retrieved and were used to assess the level of evidence of a potential benefit to prescribing an AD. For 15 conditions, there was a consensus that prescribing an AD was beneficial. For 5 others, ADs were seen as potentially beneficial. No proof of benefit was found for 15 conditions and proof of no benefit was found for the last 9. There were higher levels of evidence for pain conditions, (neuropathic pain, diabetic painful neuropathy, central neuropathic pain, migraine, tension-type headaches, and fibromyalgia) incontinence and irritable bowel syndrome. There were difficulties in summarizing the data, due to a lack of information on the level of evidence, and due to variations in efficacy between and among the various classes of ADs.ConclusionsPrescription of ADs was found to be beneficial for many non-psychiatric health conditions regularly encountered in PC settings. On the whole, the guidelines were heterogeneous, seemingly due to a lack of trials assessing the role of ADs in treatment strategies.

Project description:AimTo identify indicators sensitive to the practice of primary healthcare nurse practitioners (PHCNPs).Materials and methodsA review of systematic reviews was undertaken to identify indicators sensitive to PHCNP practice. Published and grey literature was searched from January 1, 2010 to December 2, 2022. Titles/abstracts (n = 4251) and full texts (n = 365) were screened independently by two reviewers, with a third acting as a tie-breaker. Reference lists of relevant publications were reviewed. Risk of bias was examined independently by two reviewers using AMSTAR-2. Data were extracted by one reviewer and verified by a second reviewer to describe study characteristics, indicators, and results. Indicators were recoded into categories. Findings were summarized using narrative synthesis.ResultsForty-four systematic reviews were retained including 271 indicators that were recoded into 26 indicator categories at the patient, provider and health system levels. Nineteen reviews were assessed to be at low risk of bias. Patient indicator categories included activities of daily living, adaptation to health conditions, clinical conditions, diagnosis, education-patient, mortality, patient adherence, quality of life, satisfaction, and signs and symptoms. Provider indicator categories included adherence to best practice-providers, education-providers, illness prevention, interprofessional team functioning, and prescribing. Health system indicator categories included access to care, consultations, costs, emergency room visits, healthcare service delivery, hospitalizations, length of stay, patient safety, quality of care, scope of practice, and wait times.DiscussionEqual to improved care for almost all indicators was found consistently for the PHCNP group. Very few indicators favoured the control group. No indicator was identified for high/low fidelity simulation, cultural safety and cultural sensitivity with people in vulnerable situations or Indigenous Peoples.ConclusionThis review of systematic reviews identified patient, provider and health system indicators sensitive to PHCNP practice. The findings help clarify how PHCNPs contribute to care outcomes.Prospero registration numberCRD42020198182.

Project description:BackgroundThe underuse or overuse of knowledge products leads to waste in health care, and primary care is no exception.ObjectiveThis study aimed to characterize which knowledge products are frequently implemented, the implementation strategies used in primary care, and the implementation outcomes that are measured.MethodsWe performed a systematic review (SR) of SRs using the Cochrane systematic approach to include eligible SRs. The inclusion criteria were any primary care contexts, health care professionals and patients, any Effective Practice and Organization of Care implementation strategies of specified knowledge products, any comparators, and any implementation outcomes based on the Proctor framework. We searched the MEDLINE, EMBASE, CINAHL, Ovid PsycINFO, Web of Science, and Cochrane Library databases from their inception to October 2019 without any restrictions. We searched the references of the included SRs. Pairs of reviewers independently performed selection, data extraction, and methodological quality assessment by using A Measurement Tool to Assess Systematic Reviews 2. Data extraction was informed by the Effective Practice and Organization of Care taxonomy for implementation strategies and the Proctor framework for implementation outcomes. We performed a descriptive analysis and summarized the results by using a narrative synthesis.ResultsOf the 11,101 records identified, 81 (0.73%) SRs were included. Of these 81, a total of 47 (58%) SRs involved health care professionals alone. Moreover, 15 SRs had a high or moderate methodological quality. Most of them addressed 1 type of knowledge product (56/81, 69%), common clinical practice guidelines (26/56, 46%) or management, and behavioral or pharmacological health interventions (24/56, 43%). Mixed strategies were used for implementation (67/81, 83%), predominantly education-based (meetings in 60/81, 74%; materials distribution in 59/81, 73%; and academic detailing in 45/81, 56%), reminder (53/81, 36%), and audit and feedback (40/81, 49%) strategies. Education meetings (P=.13) and academic detailing (P=.11) seemed to be used more when the population was composed of health care professionals alone. Improvements in the adoption of knowledge products were the most commonly measured outcome (72/81, 89%). The evidence level was reported in 12% (10/81) of SRs on 62 outcomes (including 48 improvements in adoption), of which 16 (26%) outcomes were of moderate or high level.ConclusionsClinical practice guidelines and management and behavioral or pharmacological health interventions are the most commonly implemented knowledge products and are implemented through the mixed use of educational, reminder, and audit and feedback strategies. There is a need for a strong methodology for the SR of randomized controlled trials to explore their effectiveness and the entire cascade of implementation outcomes.

Project description:BackgroundThe gender gap in physician pay is often attributed in part to women working fewer hours than men, but evidence to date is limited by self-report and a lack of detail regarding clinical revenue and gender differences in practice style.MethodsUsing national all-payer claims and data from electronic health records, we conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practices. Our primary independent variable was physician gender; outcomes included visit revenue, visit counts, days worked, and observed visit time (interval between the initiation and the termination of a visit). We created multivariable regression models at the year, day, and visit level after adjustment for characteristics of the primary care physicians (PCPs), patients, and types of visit and for practice fixed effects.ResultsIn 2017, female PCPs generated 10.9% less revenue from office visits than their male counterparts (-$39,143.2; 95% confidence interval [CI], -53,523.0 to -24,763.4) and conducted 10.8% fewer visits (-330.5 visits; 95% CI, -406.6 to -254.3) over 2.6% fewer clinical days (-5.3 days; 95% CI, -7.7 to -3.0), after adjustment for age, academic degree, specialty, and number of sessions worked per week, yet spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6). These results were consistent in subgroup analyses according to the gender and health status of the patients and the type and complexity of the visits.ConclusionsFemale PCPs generated less visit revenue than male colleagues in the same practices owing to a lower volume of visits, yet spent more time in direct patient care per visit, per day, and per year. (Funded in part by the Robert Wood Johnson Foundation.).

Dataset Information

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews.

Background

Design

Methods

Results

Conclusions

Systematic review registration

Publications

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews.

Similar Datasets

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