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Patient-mediated interventions to improve professional practice

Abstract

Background

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approachesto influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patientmediated interventions. These interventionsare aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patientmediated interventionsinclude 1) patient‐reported health information, 2) patientinformation, 3) patient education, 4) patient feedback about clinicalpractice, 5) patient decision aids, 6) patients, or patientrepresentatives, being members of a committee or board, and 7)patient‐led training or education of healthcare professionals.

Objectives

To assess the effectiveness of patientmediated interventions on healthcare professionals’ performance (adherence to clinicalpractice guidelines or recommendations for clinical practice).

Search methods

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

Selection criteria

Randomised studies comparing patientmediated interventions toeither usual care or other interventions to improve professionalpractice.

Data collection and analysis

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel‐Haenszel statistics and the random‐effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

Main results

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to167 where this was reported. The included studies evaluated four types of patientmediated interventions: 1) patient‐reported health information interventions (for instance information obtained from patients about patients’ own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended toincrease patients’ knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patientmediated intervention a separate meta‐analysis was produced.

Patient‐reported health information interventions probably improvehealthcare professionals’ adherence to recommended clinicalpractice (moderate‐certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient‐reported health information interventionson desirable patient health outcomes and patient satisfaction (very low‐certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.

Patient information interventions may improve healthcare professionals’ adherence to recommended clinical practice (low‐certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes andpatient satisfaction (low‐certainty evidence). We are uncertain about the effect of patient information interventions on undesirablepatient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.

Patient education interventions probably improve healthcare professionals’ adherence to recommended clinical practice(moderate‐certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient educationinterventions may slightly increase the number of patients with desirable health outcomes (low‐certainty evidence). Undesirablepatient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

Patient decision aid interventions may have little or no effect on healthcare professionals’ adherence to recommended clinicalpractice (low‐certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patientsatisfaction, adverse events and resource use were not reported in the included studies.

Authors’ conclusions

We found that two types of patientmediated interventions, patient‐reported health information and patient education, probablyimprove professional practice by increasing healthcare professionals’ adherence to recommended clinical practice(moderate‐certainty evidence). We consider the effect to be small tomoderate. Other patientmediated interventions, such as patientinformation may also improve professional practice (low‐certainty evidence). Patient decision aids may make little or no difference tothe number of healthcare professionals’ adhering to recommended clinical practice (low‐certainty evidence).

The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due tovery low certainty evidence or lack of evidence.

Plain language summary

Patientmediated interventions to improve professionalpractice

What is the aim of the review?

Our aim with this Cochrane review was to assess whether patients can change the performance of healthcare professionals. We collected and analysed all relevant studies to answer this question and found 25 studies.

Key message

This review suggests that patients may change healthcare professionals’ practice though the following three strategies: 1) strategies where patients give healthcare professionals information about themselves; 2) strategies where patients are given healthcare information; and 3) strategies where patients take part in patienteducation. Patient decision aids may make little or no difference tohealthcare professionals’ practice, however, the certainty is low, and these results should be interpreted carefully. We still need more research about the best ways in which patients can changeprofessional practice and about the impact it has on patients’ health.

What was studied in the review?

Many strategies have been tested to see if they can improvehealthcare professionals’ practice and make sure that patients receive the best available care. These strategies include sending reminders to healthcare professionals, giving them further education, or giving them financial rewards. These strategies have mostly had only small or moderate effects. Another way of changing what healthcare professionals do is through the patients themselves. These strategies are called ‘patientmediated interventions‘.

What are the main results of the review?

The studies in this review assessed different patientmediatedstrategies compared to usual care or no strategies.

Strategies where patients give information to healthcare professionals

In these studies, patients gave information about their own health, concerns or needs to the doctor. This was usually done by filling in a questionnaire in the waiting area before a consultation. The doctor was then given this information before or at the consultation. The review shows that these strategies:

‐ probably improve the extent to which healthcare professionals follow recommended clinical practice (moderate‐certainty evidence).

We are uncertain about the effect of these strategies on patienthealth, patient satisfaction and resource use because these outcomes were not measured in the studies or because the certainty of the evidence is very low.

Strategies where information was given to patients

In these studies, patients were given information about recommended care or were reminded to use services, for instance togo for a check‐up. The review shows that these strategies:

‐ may improve the extent to which healthcare professionals follow recommended clinical practice (low‐certainty evidence);

‐ may have little or no effect on patient satisfaction (low‐certainty evidence);

‐ may have little or no effect on some patient health outcomes, such as the number of patients who reach controlled blood pressure (low‐certainty evidence). However, we are uncertain about the effect of these strategies on other patient health outcomes because the certainty of the evidence is very low. We also lack information todraw conclusions about resource use.

Patient education strategies

In these studies, patients took part in patient education such as self‐management programmes, for instance to increase their knowledge about their condition. The review shows that these strategies:

‐ probably improve the extent to which healthcare professionals follow recommended clinical practice (moderate‐certainty evidence);

‐ may slightly improve some patient health outcomes such as the number of patients who reach controlled blood pressure (low‐certainty evidence). However, we are uncertain about the effect of these strategies on other patient health outcomes, patientsatisfaction and resource use because these outcomes were not measured in the included studies.

Patient decision aid strategies

In the one study that assessed effect of patient decision aids, patients were given a decision aid consisting of a booklet, personal worksheet, and audiotape to make decisions about their medical management. The review shows that these strategies:

‐ may have little or no effect on the extent to which healthcare professionals follow recommended clinical practice (low‐certainty evidence)

We are uncertain about the effect of these strategies on patienthealth, patient satisfaction and resource use because these outcomes were not measured in the studies or because the certainty of the evidence is very low.

How up‐to‐date is this review?

We searched for studies up to March 2018 and ongoing studies up toOctober 2017.

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