Open access Research Developing a new clinical governance ... · buja A etfial BM Open 20188e020626...
Transcript of Open access Research Developing a new clinical governance ... · buja A etfial BM Open 20188e020626...
1Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review
Alessandra Buja,1 Roberto Toffanin,2 Mirko Claus,3 Walter Ricciardi,4 Gianfranco Damiani,4 Vincenzo Baldo,1 Mark H Ebell5
To cite: Buja A, Toffanin R, Claus M, et al. Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
► Prepublication history for this paper is available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 020626).
Received 16 November 2017Revised 18 April 2018Accepted 20 April 2018
For numbered affiliations see end of article.
Correspondence toDr Alessandra Buja; alessandra. buja@ unipd. it
Research
© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
AbstrACtObjectives Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.setting Primary care.Participants Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.Interventions We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.results All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.Conclusions A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.
IntrOduCtIOn The dramatic increase in the burden of chronic diseases in the last 20 years represents a primary concern for health services, and
global health system sustainability demands a massive shift to primary care.1–3 As a conse-quence, the organisation and provision of primary care now faces new challenges (eg, polypharmacy, multimorbidity, fragmenta-tion of care, frequent transitions of care, a need for strong integration and pressure from patients).4 There is currently a growing interest in high-income countries to rede-sign healthcare organisations, focusing on practices that improve the quality of care and guarantee the equitable, timely and effec-tive management of patients with chronic diseases.5 6 In fact, it is now widely recognised that the care and support needed to live with a long-term condition requires a radical re-design of services, by allowing patients to drive the care planning process and by developing a new management of care for people that is proactive, holistic, preventive and patient-centred as for example defined by the ‘House of Care’ model.7 With these pressures, primary care systems may have difficulty ensuring a coordinated approach, and the lack of clarity concerning their goals has led to divergent approaches, and a slow and often disjointed adoption of changes and improvements.8
Clinical governance is an umbrella for the systematic administration and coordina-tion of different processes having a direct impact on healthcare delivery, including
strengths and limitations of this study
► The study gives a new comprehensive framework to drive an effective management of chronic diseases in the primary care setting.
► A systematic review was made showing all rel-evant studies in Cochrane Effective Practice and Organisation of Care Group alongside the dimen-sions of the framework.
► We do not report studies illustrating interventions for a specific unique disease even if chronic disease.
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
2 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
the management of patients with chronic conditions. It encompasses the tools, methods and infrastructure devoted to assuring healthcare delivery, continuously improving the quality of the service and striving towards clinical excellence for patients. Clinical governance was first established in the UK,9 and has been implemented in many different countries.10–13 Until now, it has focused largely on in-hospital care, and met with significant difficulties when transferred to primary care.14 Clinical governance for primary care, focusing on the manage-ment of chronic diseases, has specific features and relies on a network of different health professionals working together for their patients’ benefit.15
Our paper aims to conceptualise a clinical gover-nance framework and the tools it needs for the effective management of chronic diseases in the primary care setting, allowing to drive an effective change in health-care services and thereby systematically improving their quality and safety.
MethOdsFor the purposes of our analysis, we used the Chronic Care Model by Wagner et al16 and Clinical Governance statement by Scally et al17 for reference, carefully reviewing each of them and their various components. We then conceptualised a new framework, merging the relevant aspects of both, and also defining and implementing new themes in a way that is relevant for primary care. We ultimately selected five core elements from the original Chronic Care Model (delivery system design, decision support, clinical information systems, self-management support, the community) and six approaches (risk avoid-ance, coherence, infrastructure, culture, quality methods, poor performance) from the clinical governance frame-work described by Scally et al based on their relevance to primary care and chronic disease management.
We then devised a framework arranged like a sunflower, where the stem and leaves represent the structural components of the system needed to supply and support the petals. The petals in turn represent the themes or topics that shape direct actions involving patients or caregivers (the bud of the system). The sunflower is rooted in the earth, from where its structural components receive inputs in the form of water and nutrients; in healthcare, inputs from the ‘soil’ enable the provision of primary care, collabo-ration between service providers and resources from the outside world. The atmosphere in which the sunflower grows informs the views and attitudes that guide the actions of both health professionals and patients.
For each petal (ie, theme or topic), we searched for rele-vant interventions in the Cochrane Library from 2010 to the end of 2016, in the context of chronic care in the primary care setting. The search strategy used in our umbrella review of the Cochrane Library was based on the MeSH terms: (‘general practice*’ or ‘primary care’) and (‘chronic disease*’ or ‘multimorbidity’), plus one of the following: (1) ‘clinical governance’; (2) ‘quality
assurance’ or ‘evidence-based healthcare’; (3) ‘satisfac-tion, patient’; (4) ‘risk management’; (5) ‘empowerment’ or ‘health literacy’ or ‘engagement’; (6) ‘health tech-nology assessment’ or ‘cost-effectiveness’ or ‘cost-utility’. We also identified all systematic reviews published by the Cochrane Effective Practice and Organisation of Care (EPOC) Group that met our criteria. We included all relevant studies published in the Cochrane Review Data-base from 2010 to June 2017, and excluded all studies illustrating interventions for a specific disease, or those not involving patients with chronic disease.
Patient and public involvementThe present study does not involve patients or public.
resultsThe resulting conceptual framework is shown in figure 1. We define three targets where management strategies could be acted:1. The petals consist of the management strategies that
directly inform the interventions and clinical practice that acts on and with the patient and their family; pri-mary care delivery happens at the level of the petals level, with the patient at the centre.
2. The stem represents the underpinning management strategies that support the delivery system, which is the personnel and structures that permit the organisation to support the ‘life of the petals’.
Figure 1 Framework for primary care management of chronic disease. EBHC, Evidence-based healthcare.
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
3Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
3. The ground is the environment in which primary care delivery is located, which gives ‘nourishment’ and foundation.
4. Finally, there is the atmosphere, which represents the management strategies that influence the first three targets.
the bud is the centre of the flowerPlacing personalised patient-centred care at the heart of the system is an important way to create catalysts for change and encourage service re-organisation, by focusing on patients’ health needs and motivating health system changes.18 We define patient-centred care as care that is based on continuous, healing relationships among health professionals, patients and their families; care that is customised based on the patients’ needs and values19; ensuring that the patient is the source of control; sharing knowledge and information freely and maintaining transparency.
the petals define what and how to act on and with the patientsThe petals represent the management strategies that should shape directly the interventions on and with the patients. These dimensions include quality management, perceived quality management, empowerment strategies, risk management and health technology assessment. The Institute of Medicine in the USA (now called National Academy of Medicine) defines quality management as the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.20 It usually has two facets: quality assurance and quality improvement. In chronic disease manage-ment, quality assurance concerns the activities and programmes intended to assure or improve the quality of care in a specified medical setting or programme. The concept includes assessing (measuring) the quality of care, identifying problems or shortcomings in the delivery of care, designing activities to overcome these deficiencies and follow-up monitoring to ensure the effectiveness of any corrective action.21 Quality improve-ment involves the process of attaining a new, higher level of performance or quality.22 Adopting the philosophy of evidence-based medicine in planning the diagnosis, care and follow-up of chronic patients has resulted in a more effective and consistent transfer of the lessons learnt from research into routine practice, helping to reach higher quality standards.23 24 For example, a review showed that, in 5 of 17 good-quality randomised controlled trials, several different interventions were able to improve both adherence to prescribed medicines and clinical outcomes. These interventions frequently included enhancing support from family, peers or allied health professionals such as pharmacists, who often delivered education, counselling or daily treatment support, even if no common features could be identified to explain their success25 (table 1A).
However, while many measures of quality of care in the primary care setting have been validated for specific diseases, little has been done to examine the validity or usefulness of these measures in the context of multimor-bidity. To guarantee quality assurance, it is necessary to consider the deliberate and systematic coordination of an organisation’s people, technology, processes and organisa-tional structure in order to add value through innovation, using research to inform practice.26 The systematic coor-dination and organisation of the primary healthcare team to develop proactive, holistic, preventive and patient-cen-tred models of care has primarily been developed for patients with chronic disease and multimorbidity. A review27 concluded that health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings improved mainly mental health and functional outcomes. Another study28 demonstrated the benefits of applying new technologies (telemonitoring) for commu-nity-dwelling patients care with chronic disease and multi-morbidity, which significantly reduced healthcare costs, hospital emergency department admissions, hospital length of stay and mortality.
Risk management concerns the systematic identification, assessment and integrated management of current and potential hazards relating to patient care. This is partic-ularly relevant for the care of complex patients with (‘multimorbidity’).28 The creation of a culture that is free of blame and encourages an open examination of errors and failures is key to improving quality and learning.
Clinical incident reporting is a key feature of a risk management system that can improve identification of errors and how we can learn from them. Leape suggests that successful systems provide a safe non-punitive envi-ronment, and are simple, timely and inexpensive.29 However, the effectiveness of such systems in promoting adverse event recording is not clear. To evaluate the effects of interventions designed to increase clinical inci-dent reporting in healthcare settings, Parmelli et al in 2012 conducted a review of four trials with several meth-odological shortcomings. Despite their limitations, two studies showed the effectiveness of the system implemen-tation: one reported an increase in incident reporting rates, while the second showed a sustained improvement after 9 months.30
One review on non-clinical health professional roles found that older people were more likely to receive appropriate medicines with the provision of a pharma-cist-led intervention.31 This service provided by phar-macists that involves identifying, preventing and solving medication-related problems, as well as promoting the correct use of medicines and encouraging health promotion and education. Another strategy found to be useful was computerised support for decision-making. The review focused primarily on process outcomes, and provided only limited evidence of whether these interven-tions resulted in clinical improvement. Another review found that self-monitoring of medicines and patient
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
4 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Tab
le 1
S
yste
mat
ic r
evie
ws
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
A: S
yste
mat
ic r
evie
ws
abo
ut q
ualit
y im
pro
vem
ent
Nie
uwla
at R
et
al25
Inte
rven
tions
for
enha
ncin
g m
edic
atio
n ad
here
nce
The
prim
ary
obje
ctiv
e of
thi
s re
view
is t
o as
sess
the
ef
fect
s of
inte
rven
tions
inte
nded
to
enha
nce
pat
ient
ad
here
nce
to p
resc
ribed
med
icat
ions
for
med
ical
co
nditi
ons,
on
bot
h m
edic
atio
n ad
here
nce
and
cl
inic
al o
utco
mes
.
We
incl
uded
unc
onfo
und
ed r
and
omis
ed c
ontr
olle
d t
rials
(RC
Ts) o
f in
terv
entio
ns t
o im
pro
ve a
dhe
renc
e w
ith p
resc
ribed
med
icat
ions
, m
easu
ring
bot
h m
edic
atio
n ad
here
nce
and
clin
ical
out
com
e, w
ith
at le
ast
80%
follo
w-u
p o
f eac
h gr
oup
stu
die
d a
nd, f
or lo
ng-t
erm
tr
eatm
ents
, at
leas
t 6
mon
ths
follo
w-u
p fo
r st
udie
s w
ith p
ositi
ve
find
ings
at
earli
er t
ime
poi
nts.
The
pr e
sent
up
dat
e in
clud
ed 1
09 n
ew s
tud
ies,
brin
ging
the
tot
al n
umb
er t
o 18
2.
In t
he 1
7 st
udie
s of
the
hig
hest
qua
lity,
inte
rven
tions
wer
e ge
nera
lly c
omp
lex
with
se
vera
l diff
eren
t w
ays
to t
ry t
o im
pro
ve m
edic
ine
adhe
renc
e. T
hese
freq
uent
ly
incl
uded
enh
ance
d s
upp
ort
from
fam
ily, p
eers
or
allie
d h
ealth
pro
fess
iona
ls s
uch
as
pha
rmac
ists
, who
oft
en d
eliv
ered
ed
ucat
ion,
cou
nsel
ling
or d
aily
tre
atm
ent
sup
por
t.
Onl
y fiv
e of
the
se R
CTs
imp
rove
d b
oth
med
icin
e ad
here
nce
and
clin
ical
out
com
es,
and
no
com
mon
cha
ract
eris
tics
for
thei
r su
cces
s co
uld
be
iden
tified
. Ove
rall,
eve
n th
e m
ost
effe
ctiv
e in
terv
entio
ns d
id n
ot le
ad t
o la
rge
imp
rove
men
ts.
Sm
ith S
M e
t al
27In
terv
entio
ns fo
r im
pro
ving
out
com
es
in p
atie
nts
with
m
ultim
orb
idity
in
prim
ary
care
and
co
mm
unity
set
tings
To d
eter
min
e th
e ef
fect
iven
ess
of h
ealth
-ser
vice
or
pat
ient
-orie
nted
inte
rven
tions
des
igne
d t
o im
pro
ve
outc
omes
in p
eop
le w
ith m
ultim
orb
idity
in p
rimar
y ca
re a
nd c
omm
unity
set
tings
. Mul
timor
bid
ity w
as
defi
ned
as
two
or m
ore
chro
nic
cond
ition
s in
the
sa
me
ind
ivid
ual.
We
cons
ider
ed R
CTs
, non
-ran
dom
ised
clin
ical
tria
ls (N
RC
Ts),
cont
rolle
d b
efor
e-af
ter
stud
ies
(CB
As)
and
inte
rrup
ted
tim
e se
ries
anal
yses
(ITS
) eva
luat
ing
inte
rven
tions
to
imp
rove
ou
tcom
es fo
r p
eop
le w
ith m
ultim
orb
idity
in p
rimar
y ca
re a
nd
com
mun
ity s
ettin
gs. T
his
incl
udes
stu
die
s w
here
par
ticip
ants
ca
n ha
ve c
omb
inat
ions
of a
ny c
ond
ition
or
have
com
bin
atio
ns o
f p
resp
ecifi
ed c
omm
on c
ond
ition
s. T
he c
omp
aris
on w
as u
sual
car
e as
del
iver
ed in
tha
t se
ttin
g.
Ove
rall,
the
res
ults
reg
ard
ing
the
effe
ctiv
enes
s of
inte
rven
tions
wer
e m
ixed
. The
re
wer
e no
cle
ar p
ositi
ve im
pro
vem
ents
in c
linic
al o
utco
mes
, hea
lth s
ervi
ce u
se,
med
icat
ion
adhe
renc
e, p
atie
nt-r
elat
ed h
ealth
beh
avio
urs,
hea
lth p
rofe
ssio
nal
beh
avio
urs
or c
osts
. The
re w
ere
mod
est
imp
rove
men
ts in
men
tal h
ealth
out
com
es
from
sev
en s
tud
ies
that
tar
gete
d p
eop
le w
ith d
epre
ssio
n, a
nd in
func
tiona
l out
com
es
from
tw
o st
udie
s ta
rget
ing
func
tiona
l diffi
culti
es in
par
ticip
ants
. Ove
rall,
the
res
ults
in
dic
ate
that
it is
diffi
cult
to im
pro
ve o
utco
mes
for
peo
ple
with
mul
tiple
con
diti
ons.
Th
e re
view
sug
gest
s th
at in
terv
entio
ns t
hat
are
des
igne
d t
o ta
rget
sp
ecifi
c ris
k fa
ctor
s (e
g, t
reat
men
t fo
r d
epre
ssio
n) o
r in
terv
entio
ns t
hat
focu
s on
diffi
culti
es t
hat
peo
ple
exp
erie
nce
with
dai
ly fu
nctio
ning
(eg,
phy
siot
hera
py
trea
tmen
t to
imp
rove
ca
pac
ity fo
r p
hysi
cal a
ctiv
ity) m
ay b
e m
ore
effe
ctiv
e. T
here
is a
nee
d fo
r fu
rthe
r st
udie
s on
thi
s to
pic
, par
ticul
arly
invo
lvin
g p
eop
le w
ith m
ultim
orb
idity
in g
ener
al
acro
ss t
he a
ge r
ange
s.
Ard
iti C
et
al77
Com
put
er-g
ener
ated
re
min
der
s d
eliv
ered
on
pap
er t
o he
alth
care
p
rofe
ssio
nals
; effe
cts
on p
rofe
ssio
nal
pra
ctic
e an
d
heal
thca
re o
utco
mes
To e
valu
ate
the
ben
efits
and
har
ms
of r
ehab
ilita
tion
inte
rven
tions
dire
cted
at
mai
ntai
ning
, or
imp
rovi
ng,
phy
sica
l fun
ctio
n fo
r ol
der
peo
ple
in lo
ng-t
erm
car
e th
roug
h th
e re
view
of R
CTs
clu
ster
RC
Ts (C
RC
Ts).
We
incl
uded
ind
ivid
ual o
r C
RC
Ts R
CTs
and
NR
CTs
tha
t ev
alua
ted
th
e im
pac
t of
com
put
er-g
ener
ated
rem
ind
ers
del
iver
ed o
n p
aper
to
hea
lthca
re p
rofe
ssio
nals
on
pro
cess
es a
nd/o
r ou
tcom
es o
f ca
re.
Ther
e is
mod
erat
e q
ualit
y ev
iden
ce t
hat
com
put
er-g
ener
ated
rem
ind
ers
del
iver
ed o
n p
aper
to
heal
thca
re p
rofe
ssio
nals
ach
ieve
mod
erat
e im
pro
vem
ent
in p
roce
ss o
f car
e.
Two
char
acte
ristic
s em
erge
d a
s si
gnifi
cant
pre
dic
tors
of i
mp
rove
men
t: p
rovi
din
g sp
ace
on t
he r
emin
der
for
a re
spon
se fr
om t
he c
linic
ian
and
pro
vid
ing
an e
xpla
natio
n of
the
rem
ind
er’s
con
tent
or
advi
ce. T
he h
eter
ogen
eity
of t
he r
emin
der
inte
rven
tions
in
clud
ed in
thi
s re
view
als
o su
gges
ts t
hat
rem
ind
ers
can
imp
rove
car
e in
var
ious
se
ttin
gs u
nder
var
ious
con
diti
ons.
Thom
as R
E e
t al
78In
terv
entio
ns t
o in
crea
se in
fluen
za
vacc
inat
ion
rate
s of
th
ose
aged
60
year
s an
d o
lder
in t
he
com
mun
ity
To a
sses
s ac
cess
, pro
vid
er, s
yste
m a
nd s
ocie
tal
inte
rven
tions
to
incr
ease
the
up
take
of i
nflue
nza
vacc
inat
ion
in p
eop
le a
ged
60
year
s an
d o
lder
in t
he
com
mun
ity.
RC
Ts o
f int
erve
ntio
ns t
o in
crea
se in
fluen
za v
acci
natio
n up
take
in
peo
ple
age
d 6
0 ye
ars
and
old
er.
Ther
e ar
e in
terv
entio
ns t
hat
are
effe
ctiv
e fo
r in
crea
sing
com
mun
ity d
eman
d fo
r va
ccin
atio
n, e
nhan
cing
acc
ess
and
imp
rovi
ng p
rovi
der
/sys
tem
res
pon
se. I
n p
artic
ular
, effe
ctiv
e in
terv
entio
ns in
thi
s co
mp
aris
on w
ere
a le
tter
plu
s le
aflet
/pos
tcar
d
com
par
ed w
ith a
lett
er, n
urse
s/p
harm
acis
ts e
duc
atin
g p
lus
vacc
inat
ing
pat
ient
s,
a p
hone
cal
l fro
m a
sen
ior,
a te
lep
hone
invi
tatio
n ra
ther
tha
n cl
inic
dro
p-i
n, fr
ee
groc
erie
s lo
tter
y an
d n
urse
s ed
ucat
ing
and
vac
cina
ting
pat
ient
s. W
e w
ere
unab
le
to p
ool t
rials
of p
ostc
ard
/lett
er/p
amp
hlet
s, c
omm
unic
atio
ns t
ailo
red
to
pat
ient
s, a
cu
stom
ised
lett
er/p
hone
cal
l or
clie
nt-b
ased
ap
pra
isal
s, b
ut s
ever
al t
rials
of t
hese
in
terv
entio
ns s
how
ed t
hey
wer
e ef
fect
ive.
Kro
gsb
øll L
T et
al79
Gen
eral
hea
lth c
heck
s in
ad
ults
for
red
ucin
g m
orb
idity
and
mor
talit
y fr
om d
isea
se
We
aim
ed t
o q
uant
ify t
he b
enefi
ts a
nd h
arm
s of
ge
nera
l hea
lth c
heck
s w
ith a
n em
pha
sis
on p
atie
nt-
rele
vant
out
com
es s
uch
as m
orb
idity
and
mor
talit
y ra
ther
tha
n on
sur
roga
te o
utco
mes
suc
h as
blo
od
pre
ssur
e an
d s
erum
cho
lest
erol
leve
ls.
We
incl
uded
RC
Ts c
omp
arin
g he
alth
che
cks
with
no
heal
th
chec
ks in
ad
ults
uns
elec
ted
for
dis
ease
or
risk
fact
ors.
We
did
no
t in
clud
e ge
riatr
ic t
rials
. We
defi
ned
hea
lth c
heck
s as
scr
eeni
ng
gene
ral p
opul
atio
ns fo
r m
ore
than
one
dis
ease
or
risk
fact
or in
m
ore
than
one
org
an s
yste
m.
Ther
e w
as n
o ef
fect
on
the
risk
of d
eath
, or
on t
he r
isk
of d
eath
due
to
card
iova
scul
ar
dis
ease
s or
can
cer.
We
did
not
find
an
effe
ct o
n th
e ris
k of
illn
ess
but
one
tria
l fo
und
an
incr
ease
d n
umb
er o
f peo
ple
iden
tified
with
hig
h b
lood
pre
ssur
e an
d h
igh
chol
este
rol,
and
one
tria
l fou
nd a
n in
crea
sed
num
ber
with
chr
onic
dis
ease
s. O
ne
tria
l rep
orte
d t
he t
otal
num
ber
of n
ew d
iagn
oses
per
par
ticip
ant
and
foun
d a
20%
in
crea
se o
ver
6 ye
ars
com
par
ed w
ith t
he c
ontr
ol g
roup
. No
tria
ls c
omp
ared
the
tot
al
num
ber
of n
ew p
resc
riptio
ns b
ut t
wo
out
of fo
ur t
rials
foun
d a
n in
crea
sed
num
ber
of
peo
ple
usi
ng d
rugs
for
high
blo
od p
ress
ure.
Tw
o ou
t of
four
tria
ls fo
und
tha
t he
alth
che
cks
mad
e p
eop
le fe
el s
omew
hat
heal
thie
r, b
ut t
his
resu
lt is
not
rel
iab
le.
We
did
not
find
tha
t he
alth
che
cks
had
an
effe
ct o
n th
e nu
mb
er o
f ad
mis
sion
s to
ho
spita
l, d
isab
ility
, wor
ry, t
he n
umb
er o
f ref
erra
ls t
o sp
ecia
lists
, ad
diti
onal
vis
its t
o th
e p
hysi
cian
or
abse
nce
from
wor
k, b
ut m
ost
of t
hese
out
com
es w
ere
poo
rly s
tud
ied
. N
one
of t
he t
rials
rep
orte
d o
n th
e nu
mb
er o
f fol
low
-up
tes
ts a
fter
pos
itive
scr
eeni
ng
resu
lts, o
r th
e am
ount
of s
urge
ry u
sed
. With
the
larg
e nu
mb
er o
f par
ticip
ants
and
d
eath
s in
clud
ed, t
he lo
ng fo
llow
-up
per
iod
s us
ed in
the
tria
ls, a
nd c
onsi
der
ing
that
d
eath
from
car
dio
vasc
ular
dis
ease
s an
d c
ance
r w
ere
not
red
uced
, gen
eral
hea
lth
chec
ks a
re u
nlik
ely
to b
e b
enefi
cial
.
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
5Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Arc
ham
bau
lt P
M80
Col
lab
orat
ive
writ
ing
app
licat
ions
in
heal
thca
re: e
ffect
s on
p
rofe
ssio
nal p
ract
ice
and
hea
lthca
re
outc
omes
The
obje
ctiv
es o
f thi
s re
view
wer
e to
: (1)
ass
ess
the
effe
cts
of t
he u
se o
f CW
As
on p
roce
ss (i
nclu
din
g th
e b
ehav
iour
of h
ealth
care
pro
fess
iona
ls) a
nd p
atie
nt
outc
omes
, (2)
crit
ical
ly a
pp
rais
e an
d s
umm
aris
e cu
rren
t ev
iden
ce o
n th
e us
e of
res
ourc
es, c
osts
and
co
st-e
ffect
iven
ess
asso
ciat
ed w
ith C
WA
s to
imp
rove
p
rofe
ssio
nal p
ract
ices
and
pat
ient
out
com
es a
nd
(3) e
xplo
re t
he e
ffect
s of
diff
eren
t C
WA
feat
ures
(eg,
op
en v
s cl
osed
) and
diff
eren
t im
ple
men
tatio
n fa
ctor
s (e
g, t
he p
rese
nce
of a
mod
erat
or) o
n p
roce
ss a
nd
pat
ient
out
com
es.
We
incl
uded
RC
Ts, N
RC
Ts, C
BA
s, IT
S s
tud
ies
and
rep
eate
d
mea
sure
s st
udie
s (R
MS
), in
whi
ch C
WA
s w
ere
used
as
an
inte
rven
tion
to im
pro
ve t
he p
roce
ss o
f car
e, p
atie
nt o
utco
mes
or
heal
thca
re c
osts
.
We
scre
ened
11
993
stud
ies
iden
tified
from
the
ele
ctro
nic
dat
abas
e se
arch
es a
nd 3
46
stud
ies
from
gre
y lit
erat
ure
sour
ces.
We
anal
ysed
the
full
text
of 9
9 st
udie
s. N
one
of
the
stud
ies
met
the
elig
ibili
ty c
riter
ia; t
wo
pot
entia
lly r
elev
ant
stud
ies
are
ongo
ing.
We
did
not
iden
tify
any
stud
ies
that
mea
sure
d t
he e
ffect
of C
WA
s on
how
hea
lthca
re
pro
fess
iona
ls c
are
for
thei
r p
atie
nts.
Fian
der
M e
t al
81In
terv
entio
ns t
o in
crea
se t
he u
se o
f el
ectr
onic
hea
lth
info
rmat
ion
(EH
I) b
y he
alth
care
p
ract
ition
ers
to
imp
rove
clin
ical
p
ract
ice
and
pat
ient
ou
tcom
es
To a
sses
s th
e ef
fect
s of
inte
rven
tions
aim
ed a
t im
pro
ving
or
incr
easi
ng h
ealth
care
pra
ctiti
oner
s’
use
of E
HI o
n p
rofe
ssio
nal p
ract
ice
and
pat
ient
ou
tcom
es.
We
incl
uded
stu
die
s th
at e
valu
ated
the
effe
cts
of in
terv
entio
ns
to im
pro
ve o
r in
crea
se t
he u
se o
f EH
I by
heal
thca
re p
ract
ition
ers
on p
rofe
ssio
nal p
ract
ice
and
pat
ient
out
com
es. W
e d
efine
d
EH
I as
info
rmat
ion
acce
ssed
on
a co
mp
uter
. We
defi
ned
‘use
’ as
logg
ing
into
EH
I. W
e co
nsid
ered
any
hea
lthca
re p
ract
ition
er
invo
lved
in p
atie
nt c
are.
We
incl
uded
RC
Ts, N
RC
Ts, a
nd C
RC
Ts,
cont
rolle
d c
linic
al t
rials
(CC
Ts),
ITS
and
CB
As.
The
com
par
ison
s w
ere:
ele
ctro
nic
vs p
rinte
d h
ealth
info
rmat
ion;
EH
I on
diff
eren
t el
ectr
onic
dev
ices
(eg,
des
ktop
, lap
top
or
tab
let
com
put
ers,
etc
; ce
ll/m
obile
pho
nes)
; EH
I via
diff
eren
t us
er in
terf
aces
; EH
I pro
vid
ed
with
or
with
out
an e
duc
atio
nal o
r tr
aini
ng c
omp
onen
t an
d E
HI
com
par
ed w
ith n
o ot
her
typ
e or
sou
rce
of in
form
atio
n.
The
resu
lts o
f thi
s re
view
sho
wed
tha
t w
hen
pro
vid
ed w
ith a
com
bin
atio
n of
EH
I an
d t
rain
ing,
pra
ctiti
oner
s us
ed t
he in
form
atio
n m
ore
ofte
n. T
wo
stud
ies
mea
sure
d
doc
tors
' use
of e
lect
roni
c tr
eatm
ent
guid
elin
es, b
ut s
how
ed t
hat
the
elec
tron
ic
asp
ect
of t
he g
uid
elin
es d
id n
ot m
ean
that
doc
tors
follo
wed
the
gui
del
ines
. Thi
s re
view
pro
vid
ed n
o in
form
atio
n on
whe
ther
mor
e fr
eque
nt u
se o
f EH
I tra
nsla
ted
into
im
pro
ved
clin
ical
pra
ctic
e or
whe
ther
pat
ient
s w
ere
bet
ter
off w
hen
doc
tors
or
nurs
es
used
hea
lth in
form
atio
n w
hen
trea
ting
them
.
Flod
gren
G e
t al
83To
ols
dev
elop
ed a
nd
dis
sem
inat
ed b
y gu
idel
ine
pro
duc
ers
to
pro
mot
e th
e up
take
of
thei
r gu
idel
ines
To e
valu
ate
the
effe
ctiv
enes
s of
imp
lem
enta
tion
tool
s d
evel
oped
and
dis
sem
inat
ed b
y gu
idel
ine
pro
duc
ers,
w
hich
acc
omp
any
or fo
llow
the
pub
licat
ion
of a
C
PG
, to
pro
mot
e up
take
. A s
econ
dar
y ob
ject
ive
is t
o d
eter
min
e w
hich
ap
pro
ache
s to
gui
del
ine
imp
lem
enta
tion
are
mos
t ef
fect
ive.
We
incl
uded
RC
Ts a
nd C
RC
Ts, C
BA
s an
d IT
S s
tud
ies
eval
uatin
g th
e ef
fect
s of
gui
del
ine
imp
lem
enta
tion
tool
s d
evel
oped
by
reco
gnis
ed g
uid
elin
e p
rod
ucer
s to
imp
rove
the
up
take
of t
heir
own
guid
elin
es. T
he g
uid
elin
e co
uld
tar
get
any
clin
ical
are
a.
Two
of t
he fo
ur in
clud
ed s
tud
ies
rep
orte
d o
n ho
w w
ell h
ealth
care
pro
fess
iona
ls
stic
k to
gui
del
ine
reco
mm
end
atio
ns w
hen
pro
vid
ing
care
to
thei
r p
atie
nts,
d
epen
din
g on
whe
ther
the
y re
ceiv
ed a
CP
G w
ith a
too
l aim
ed a
t im
pro
ving
the
use
of
the
CP
G, o
r if
they
rec
eive
d t
he C
PG
onl
y. T
he r
esul
ts o
f thi
s re
view
sho
w t
hat
heal
thca
re p
rofe
ssio
nals
who
rec
eive
d a
gui
del
ine
tool
tog
ethe
r w
ith t
he C
PG
on
the
man
agem
ent
of n
on-s
pec
ific
low
bac
k p
ain
or o
rder
ing
thyr
oid
-fun
ctio
n te
sts
pro
bab
ly s
tick
mor
e cl
osel
y to
the
rec
omm
end
atio
ns, c
omp
ared
with
tho
se w
ho
rece
ived
the
CP
G o
nly.
A g
uid
elin
e to
ol a
imed
at
imp
rovi
ng t
he u
se o
f a g
uid
elin
e,
may
lead
to
little
or
no d
iffer
ence
in c
ost
to t
he h
ealth
ser
vice
.
Che
n C
E e
t al
84W
alk-
in c
linic
s vs
p
hysi
cian
offi
ces
and
em
erge
ncy
room
s fo
r ur
gent
car
e an
d
chro
nic
dis
ease
m
anag
emen
t
To a
sses
s th
e q
ualit
y of
car
e an
d p
atie
nt s
atis
fact
ion
of w
alk-
in c
linic
s co
mp
ared
with
tha
t of
tra
diti
onal
p
hysi
cian
offi
ces
and
em
erge
ncy
room
s fo
r p
eop
le
who
pre
sent
with
bas
ic m
edic
al c
omp
lain
ts fo
r ei
ther
ac
ute
or c
hron
ic is
sues
.
Stu
dy
des
ign:
RC
Ts, N
RC
Ts a
nd C
BA
s. P
opul
atio
n: s
tand
alon
e p
hysi
cal c
linic
s no
t re
qui
ring
adva
nce
app
oint
men
ts o
r re
gist
ratio
n, t
hat
pro
vid
ed b
asic
med
ical
car
e w
ithou
t ex
pec
tatio
n of
follo
w-u
p. C
omp
aris
ons:
tra
diti
onal
prim
ary
care
pra
ctic
es o
r em
erge
ncy
room
s.
Wal
k-in
clin
ics
are
grow
ing
in p
opul
arity
aro
und
the
wor
ld, b
ut it
is u
ncle
ar if
the
m
edic
al c
are
pro
vid
ed b
y w
alk-
in c
linic
s is
com
par
able
to
that
of p
hysi
cian
s' o
ffice
s or
em
erge
ncy
room
s.
Sco
tt A
et
al85
The
effe
ct o
f fina
ncia
l in
cent
ives
on
the
qua
lity
of h
ealth
care
p
rovi
ded
by
prim
ary
care
phy
sici
ans
(PC
Ps)
The
aim
of t
his
revi
ew is
to
exam
ine
the
effe
ct o
f ch
ange
s in
the
met
hod
and
leve
l of p
aym
ent
on t
he
qua
lity
of c
are
pro
vid
ed b
y P
CP
s an
d t
o id
entif
y:i.
the
diff
eren
t ty
pes
of fi
nanc
ial i
ncen
tives
tha
t ha
ve im
pro
ved
qua
lity;
ii.
the
char
acte
ristic
s of
pat
ient
pop
ulat
ions
for
who
m q
ualit
y of
car
e ha
s b
een
imp
rove
d b
y fin
anci
al in
cent
ives
;iii
. th
e ch
arac
teris
tics
of P
CP
s w
ho h
ave
resp
ond
ed
to fi
nanc
ial i
ncen
tives
.
RC
Ts, C
BA
s an
d IT
S e
valu
atin
g th
e im
pac
t of
diff
eren
t fin
anci
al
inte
rven
tions
on
the
qua
lity
of c
are
del
iver
ed b
y P
CP
s. Q
ualit
y of
ca
re w
as d
efine
d a
s p
atie
nt-r
epor
ted
out
com
e m
easu
res,
clin
ical
b
ehav
iour
s an
d in
term
edia
te c
linic
al a
nd p
hysi
olog
ical
mea
sure
s.
The
use
of fi
nanc
ial i
ncen
tives
to
rew
ard
PC
Ps
for
imp
rovi
ng t
he q
ualit
y of
prim
ary
heal
thca
re s
ervi
ces
is g
row
ing.
How
ever
, the
re is
insu
ffici
ent
evid
ence
to
sup
por
t or
not
sup
por
t th
e us
e of
fina
ncia
l inc
entiv
es t
o im
pro
ve t
he q
ualit
y of
prim
ary
heal
thca
re. I
mp
lem
enta
tion
shou
ld p
roce
ed w
ith c
autio
n an
d in
cent
ive
sche
mes
sh
ould
be
mor
e ca
refu
lly d
esig
ned
bef
ore
imp
lem
enta
tion.
In a
dd
ition
to
bas
ing
ince
ntiv
e d
esig
n m
ore
on t
heor
y, t
here
is a
larg
e lit
erat
ure
dis
cuss
ing
exp
erie
nces
w
ith t
hese
sch
emes
tha
t ca
n b
e us
ed t
o d
raw
out
a n
umb
er o
f les
sons
tha
t ca
n b
e le
arnt
and
tha
t co
uld
be
used
to
influ
ence
or
mod
ify t
he d
esig
n of
ince
ntiv
e sc
hem
es. M
ore
rigor
ous
stud
y d
esig
ns n
eed
to
be
used
to
acco
unt
for
the
sele
ctio
n of
phy
sici
ans
into
ince
ntiv
e sc
hem
es. T
he u
se o
f ins
trum
enta
l var
iab
le t
echn
ique
s sh
ould
be
cons
ider
ed t
o as
sist
with
the
iden
tifica
tion
of t
reat
men
t ef
fect
s in
the
p
rese
nce
of s
elec
tion
bia
s an
d o
ther
sou
rces
of u
nob
serv
ed h
eter
ogen
eity
. In
rand
omis
ed t
rials
, car
e m
ust
be
take
n in
usi
ng t
he c
orre
ct u
nit
of a
naly
sis
and
mor
e at
tent
ion
shou
ld b
e p
aid
to
blin
din
g. S
tud
ies
shou
ld a
lso
exam
ine
the
pot
entia
l un
inte
nded
con
seq
uenc
es o
f inc
entiv
e sc
hem
es b
y ha
ving
a s
tron
ger
theo
retic
al
bas
is, i
nclu
din
g a
bro
ader
ran
ge o
f out
com
es, a
nd c
ond
uctin
g m
ore
exte
nsiv
e su
bgr
oup
ana
lysi
s. S
tud
ies
shou
ld m
ore
cons
iste
ntly
des
crib
e (i)
the
typ
e of
pay
men
t sc
hem
e at
bas
elin
e or
in t
he c
ontr
ol g
roup
, (ii)
how
pay
men
ts t
o m
edic
al g
roup
s w
ere
used
and
dis
trib
uted
with
in t
he g
roup
s an
d (i
ii) t
he s
ize
of t
he n
ew p
aym
ents
as
a p
erce
ntag
e of
tot
al r
even
ue. F
urth
er r
esea
rch
com
par
ing
the
rela
tive
cost
s an
d e
ffect
s of
fina
ncia
l inc
entiv
es w
ith o
ther
beh
avio
ur c
hang
e in
terv
entio
ns is
als
o re
qui
red
.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
6 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Youn
g et
al86
Hom
e or
fost
er h
ome
care
vs
inst
itutio
nal
long
-ter
m c
are
for
func
tiona
lly d
epen
den
t ol
der
peo
ple
To a
sses
s th
e ef
fect
s of
long
-ter
m h
ome
or fo
ster
ho
me
care
vs
inst
itutio
nal c
are
for
func
tiona
lly
dep
end
ent
old
er p
eop
le.
We
incl
uded
RC
Ts a
nd N
RC
Ts, C
BA
s an
d IT
S s
tud
ies
com
ply
ing
with
the
Coc
hran
e E
ffect
ive
Pra
ctic
e an
d O
rgan
isat
ion
of C
are
(EP
OC
) Gro
up s
tud
y d
esig
n cr
iteria
and
com
par
ing
the
effe
cts
of lo
ng-t
erm
hom
e ca
re v
s in
stitu
tiona
l car
e fo
r fu
nctio
nally
d
epen
den
t ol
der
peo
ple
.
Ther
e ar
e in
suffi
cien
t hi
gh-q
ualit
y p
ublis
hed
dat
a to
sup
por
t an
y p
artic
ular
m
odel
of c
are
for
func
tiona
lly d
epen
den
t ol
der
peo
ple
. Com
mun
ity-b
ased
car
e w
as n
ot c
onsi
sten
tly b
enefi
cial
acr
oss
all t
he in
clud
ed s
tud
ies;
the
re w
ere
som
e d
ata
sugg
estin
g th
at c
omm
unity
-bas
ed c
are
may
be
asso
ciat
ed w
ith im
pro
ved
q
ualit
y of
life
and
phy
sica
l fun
ctio
n co
mp
ared
with
inst
itutio
nal c
are.
How
ever
, co
mm
unity
alte
rnat
ives
to
inst
itutio
nal c
are
may
be
asso
ciat
ed w
ith in
crea
sed
ris
k of
hos
pita
lisat
ion.
Fut
ure
stud
ies
shou
ld a
sses
s he
alth
care
util
isat
ion,
per
form
ec
onom
ic a
naly
sis
and
con
sid
er c
areg
iver
bur
den
.
Nka
nsah
N e
t al
87E
ffect
of o
utp
atie
nt
pha
rmac
ists
' non
-d
isp
ensi
ng r
oles
on
pat
ient
out
com
es a
nd
pre
scrib
ing
pat
tern
s
To e
xam
ine
the
effe
ct o
f out
pat
ient
pha
rmac
ists
' no
n-d
isp
ensi
ng r
oles
on
pat
ient
and
hea
lth
pro
fess
iona
l out
com
es.
RC
Ts c
omp
arin
g (1
) pha
rmac
ist
serv
ices
tar
gete
d a
t p
atie
nts
vs
serv
ices
del
iver
ed b
y ot
her
heal
th p
rofe
ssio
nals
; (2)
pha
rmac
ist
serv
ices
tar
gete
d a
t p
atie
nts
vs t
he d
eliv
ery
of n
o co
mp
arab
le
serv
ice;
(3) p
harm
acis
t se
rvic
es t
arge
ted
at
heal
th p
rofe
ssio
nals
vs
ser
vice
s d
eliv
ered
by
othe
r he
alth
pro
fess
iona
ls; (
4) p
harm
acis
t se
rvic
es t
arge
ted
at
heal
th p
rofe
ssio
nals
vs
the
del
iver
y of
no
com
par
able
ser
vice
.
Onl
y on
e in
clud
ed s
tud
y co
mp
ared
pha
rmac
ist
serv
ices
with
oth
er h
ealth
p
rofe
ssio
nal s
ervi
ces,
hen
ce w
e ar
e un
able
to
dra
w c
oncl
usio
ns r
egar
din
g co
mp
aris
ons
1 an
d 3
. Mos
t in
clud
ed s
tud
ies
sup
por
ted
the
rol
e of
pha
rmac
ists
in
med
icat
ion/
ther
apeu
tic m
anag
emen
t, p
atie
nt c
ouns
ellin
g an
d p
rovi
din
g he
alth
p
rofe
ssio
nal e
duc
atio
n w
ith t
he g
oal o
f im
pro
ving
pat
ient
pro
cess
of c
are
and
clin
ical
ou
tcom
es, a
nd o
f ed
ucat
iona
l out
reac
h vi
sits
on
phy
sici
an p
resc
ribin
g p
atte
rns.
Th
ere
was
gre
at h
eter
ogen
eity
in t
he t
ypes
of o
utco
mes
mea
sure
d a
cros
s al
l stu
die
s.
Ther
efor
e, a
sta
ndar
dis
ed a
pp
roac
h to
mea
sure
and
rep
ort
clin
ical
, hum
anis
tic a
nd
pro
cess
out
com
es fo
r fu
ture
ran
dom
ised
con
trol
led
stu
die
s ev
alua
ting
the
imp
act
of o
utp
atie
nt p
harm
acis
ts is
nee
ded
. Het
erog
enei
ty in
stu
dy
com
par
ison
gro
ups,
ou
tcom
es a
nd m
easu
res
mak
es it
cha
lleng
ing
to m
ake
gene
ralis
ed s
tate
men
ts
rega
rdin
g th
e im
pac
t of
pha
rmac
ists
in s
pec
ific
sett
ings
, dis
ease
sta
tes
and
pat
ient
p
opul
atio
ns.
Gon
çalv
es-B
rad
ley
DC
et
al88
Dis
char
ge p
lann
ing
from
hos
pita
lTo
ass
ess
the
effe
ctiv
enes
s of
pla
nnin
g th
e d
isch
arge
of
ind
ivid
ual p
atie
nts
mov
ing
from
hos
pita
l.R
CTs
tha
t co
mp
ared
an
ind
ivid
ualis
ed d
isch
arge
pla
n w
ith r
outin
e d
isch
arge
car
e th
at w
as n
ot t
ailo
red
to
ind
ivid
ual p
artic
ipan
ts.
Par
ticip
ants
wer
e ho
spita
l inp
atie
nts.
A d
isch
arge
pla
n ta
ilore
d t
o th
e in
div
idua
l pat
ient
pro
bab
ly b
rings
ab
out
a sm
all
red
uctio
n in
hos
pita
l len
gth
of s
tay
and
red
uces
the
ris
k of
rea
dm
issi
on t
o ho
spita
l at
3 m
onth
s fo
llow
-up
for
old
er p
eop
le w
ith a
med
ical
con
diti
on. D
isch
arge
pla
nnin
g m
ay le
ad t
o in
crea
sed
sat
isfa
ctio
n w
ith h
ealth
care
for
pat
ient
s an
d p
rofe
ssio
nals
. Th
ere
is li
ttle
evi
den
ce t
hat
dis
char
ge p
lann
ing
red
uces
cos
ts t
o th
e he
alth
ser
vice
.
B: R
isk
man
agem
ent
Par
mel
li et
al30
Inte
rven
tions
to
incr
ease
clin
ical
in
cid
ent
rep
ortin
g in
he
alth
care
To a
sses
s th
e ef
fect
s of
inte
rven
tions
des
igne
d t
o in
crea
se c
linic
al in
cid
ent
rep
ortin
g in
hea
lthca
re
sett
ings
.
RC
Ts, C
BA
s an
d IT
S o
f int
erve
ntio
ns d
esig
ned
to
incr
ease
clin
ical
in
cid
ent
rep
ortin
g in
hea
lthca
re.
Bec
ause
of t
he li
mita
tions
of t
he s
tud
ies
it is
not
pos
sib
le t
o d
raw
con
clus
ions
for
clin
ical
pra
ctic
e. A
nyon
e in
trod
ucin
g a
syst
em in
to p
ract
ice
shou
ld g
ive
care
ful
cons
ider
atio
n to
con
duc
ting
an e
valu
atio
n us
ing
a ro
bus
t d
esig
n.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
7Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Rya
n R
et
al89
Inte
rven
tions
to
imp
rove
saf
e an
d
effe
ctiv
e m
edic
ines
us
e b
y co
nsum
ers:
an
over
view
of s
yste
mat
ic
revi
ews
To a
sses
s th
e ef
fect
s of
inte
rven
tions
whi
ch t
arge
t he
alth
care
con
sum
ers
to p
rom
ote
safe
and
effe
ctiv
e m
edic
ines
use
, by
synt
hesi
sing
rev
iew
-lev
el
evid
ence
.
We
incl
uded
sys
tem
atic
rev
iew
s p
ublis
hed
on
the
Coc
hran
e D
atab
ase
of S
yste
mat
ic R
evie
ws
and
the
Dat
abas
e of
Ab
stra
cts
of R
evie
ws
of E
ffect
s. W
e id
entifi
ed r
elev
ant
revi
ews
by
hand
se
arch
ing
dat
abas
es fr
om t
heir
star
t d
ates
to
Mar
ch 2
012.
Look
ing
acro
ss r
evie
ws,
for
mos
t ou
tcom
es, m
edic
ines
sel
f-m
onito
ring
and
sel
f-m
anag
emen
t p
rogr
amm
es a
pp
ear
gene
rally
effe
ctiv
e to
imp
rove
med
icin
es u
se,
adhe
renc
e, a
dve
rse
even
ts a
nd c
linic
al o
utco
mes
; and
to
red
uce
mor
talit
y in
peo
ple
se
lf-m
anag
ing
antit
hrom
bot
ic t
hera
py.
How
ever
, som
e p
artic
ipan
ts w
ere
unab
le t
o co
mp
lete
the
se in
terv
entio
ns, s
ugge
stin
g th
ey m
ay n
ot b
e su
itab
le fo
r ev
eryo
ne.
Oth
er p
rom
isin
g in
terv
entio
ns t
o im
pro
ve a
dhe
renc
e an
d o
ther
key
med
icin
es-u
se
outc
omes
, whi
ch r
equi
re fu
rthe
r in
vest
igat
ion
to b
e m
ore
cert
ain
of t
heir
effe
cts,
in
clud
e:
►si
mp
lified
dos
ing
regi
men
s: w
ith p
ositi
ve e
ffect
s on
ad
here
nce;
►
inte
rven
tions
invo
lvin
g p
harm
acis
ts in
med
icin
es m
anag
emen
t, s
uch
as
med
icin
es r
evie
ws
(with
pos
itive
effe
cts
on a
dhe
renc
e an
d u
se, m
edic
ines
p
rob
lem
s an
d c
linic
al o
utco
mes
) and
pha
rmac
eutic
al c
are
serv
ices
(con
sulta
tion
bet
wee
n p
harm
acis
t an
d p
atie
nt t
o re
solv
e m
edic
ines
pro
ble
ms,
dev
elop
a c
are
pla
n an
d p
rovi
de
follo
w-u
p; w
ith p
ositi
ve e
ffect
s on
ad
here
nce
and
kno
wle
dge
).S
ever
al o
ther
str
ateg
ies
show
ed s
ome
pos
itive
effe
cts,
par
ticul
arly
rel
atin
g to
ad
here
nce,
and
oth
er o
utco
mes
, but
the
ir ef
fect
s w
ere
less
con
sist
ent
over
all a
nd s
o ne
ed fu
rthe
r st
udy.
The
se in
clud
ed:
►
del
ayed
ant
ibio
tic p
resc
riptio
ns: e
ffect
ive
to d
ecre
ase
antib
iotic
use
but
with
m
ixed
effe
cts
on c
linic
al o
utco
mes
, ad
vers
e ef
fect
s an
d s
atis
fact
ion;
►
pra
ctic
al s
trat
egie
s lik
e re
min
der
s, c
ues
and
/or
orga
nise
rs, r
emin
der
pac
kagi
ng
and
mat
eria
l inc
entiv
es: w
ith p
ositi
ve, a
lthou
gh s
omew
hat
mix
ed e
ffect
s on
ad
here
nce;
►
educ
atio
n d
eliv
ered
with
sel
f-m
anag
emen
t sk
ills
trai
ning
, cou
nsel
ling,
sup
por
t,
trai
ning
or
enha
nced
follo
w-u
p; i
nfor
mat
ion
and
cou
nsel
ling
del
iver
ed t
oget
her
or e
duc
atio
n/in
form
atio
n as
par
t of
pha
rmac
ist-
del
iver
ed p
acka
ges
of c
are:
with
p
ositi
ve e
ffect
s on
ad
here
nce,
med
icin
es u
se, c
linic
al o
utco
mes
and
kno
wle
dge
, b
ut w
ith m
ixed
effe
cts
in s
ome
stud
ies;
►
finan
cial
ince
ntiv
es: w
ith p
ositi
ve, b
ut m
ixed
, effe
cts
on a
dhe
renc
e.S
ever
al s
trat
egie
s al
so s
how
ed p
rom
ise
in p
rom
otin
g im
mun
isat
ion
upta
ke, b
ut
req
uire
furt
her
stud
y to
be
mor
e ce
rtai
n of
the
ir ef
fect
s. T
hese
incl
uded
org
anis
atio
nal
inte
rven
tions
; rem
ind
ers
and
rec
all;
finan
cial
ince
ntiv
es; h
ome
visi
ts; f
ree
vacc
inat
ion;
la
y he
alth
wor
ker
inte
rven
tions
and
faci
litat
ors
wor
king
with
phy
sici
ans
to p
rom
ote
imm
unis
atio
n up
take
. Ed
ucat
ion
and
/or
info
rmat
ion
stra
tegi
es a
lso
show
ed s
ome
pos
itive
but
eve
n le
ss c
onsi
sten
t ef
fect
s on
imm
unis
atio
n up
take
, and
nee
d fu
rthe
r as
sess
men
t of
effe
ctiv
enes
s an
d in
vest
igat
ion
of h
eter
ogen
eity
.
Pat
ters
on S
M e
t al
90In
terv
entio
ns
to im
pro
ve t
he
app
rop
riate
use
of
pol
ypha
rmac
y fo
r ol
der
p
eop
le
This
rev
iew
sou
ght
to d
eter
min
e w
hich
inte
rven
tions
, al
one
or in
com
bin
atio
n, a
re e
ffect
ive
in im
pro
ving
th
e ap
pro
pria
te u
se o
f pol
ypha
rmac
y an
d r
educ
ing
med
icat
ion-
rela
ted
pro
ble
ms
in o
lder
peo
ple
.
A r
ange
of s
tud
y d
esig
ns w
ere
elig
ible
. Elig
ible
stu
die
s d
escr
ibed
in
terv
entio
ns a
ffect
ing
pre
scrib
ing
aim
ed a
t im
pro
ving
ap
pro
pria
te
pol
ypha
rmac
y in
peo
ple
age
d 6
5 ye
ars
of a
ge a
nd o
lder
in w
hich
a
valid
ated
mea
sure
of a
pp
rop
riate
ness
was
use
d (e
g, B
eers
cr
iteria
, Med
icat
ion
Ap
pro
pria
tene
ss In
dex
).
This
rev
iew
exa
min
es s
tud
ies
in w
hich
hea
lthca
re p
rofe
ssio
nals
hav
e ta
ken
actio
n to
mak
e su
re t
hat
old
er p
eop
le a
re r
ecei
ving
the
mos
t ef
fect
ive
and
saf
est
med
icat
ion
for
thei
r ill
ness
. Act
ions
tak
en in
clud
ed p
rovi
din
g p
harm
aceu
tical
ca
re, a
ser
vice
pro
vid
ed b
y p
harm
acis
ts t
hat
invo
lves
iden
tifyi
ng, p
reve
ntin
g an
d
reso
lvin
g m
edic
atio
n-re
late
d p
rob
lem
s, a
s w
ell a
s p
rom
otin
g th
e co
rrec
t us
e of
m
edic
atio
ns a
nd e
ncou
ragi
ng h
ealth
pro
mot
ion
and
ed
ucat
ion.
Ano
ther
str
ateg
y w
as c
omp
uter
ised
dec
isio
n su
pp
ort,
whi
ch in
volv
es a
pro
gram
me
on t
he d
octo
r’s
com
put
er t
hat
help
s hi
m/h
er t
o se
lect
ap
pro
pria
te t
reat
men
t.Th
is r
evie
w p
rovi
des
lim
ited
evi
den
ce t
hat
inte
rven
tions
, suc
h as
pha
rmac
eutic
al
care
, may
be
succ
essf
ul in
ens
urin
g th
at o
lder
peo
ple
are
rec
eivi
ng t
he r
ight
m
edic
ines
, but
it is
not
cle
ar w
heth
er t
his
alw
ays
resu
lts in
clin
ical
imp
rove
men
t.
Iver
s N
et
al91
Aud
it an
d fe
edb
ack:
ef
fect
s on
pro
fess
iona
l p
ract
ice
and
he
alth
care
out
com
es
To a
sses
s th
e ef
fect
s of
aud
it an
d fe
edb
ack
on t
he
pra
ctic
e of
hea
lthca
re p
rofe
ssio
nals
and
pat
ient
ou
tcom
es a
nd t
o ex
amin
e fa
ctor
s th
at m
ay e
xpla
in
varia
tion
in t
he e
ffect
iven
ess
of a
udit
and
feed
bac
k.
Ran
dom
ised
tria
ls o
f aud
it an
d fe
edb
ack
(defi
ned
as
a su
mm
ary
of c
linic
al p
erfo
rman
ce o
ver
a sp
ecifi
ed p
erio
d o
f tim
e) t
hat
rep
orte
d o
bje
ctiv
ely
mea
sure
d h
ealth
pro
fess
iona
l pra
ctic
e or
p
atie
nt o
utco
mes
. In
the
case
of m
ultif
acet
ed in
terv
entio
ns, o
nly
tria
ls in
whi
ch a
udit
and
feed
bac
k w
as c
onsi
der
ed t
he c
ore,
es
sent
ial a
spec
t of
at
leas
t on
e in
terv
entio
n ar
m w
ere
incl
uded
.
Aud
it an
d fe
edb
ack
gene
rally
lead
s to
sm
all b
ut p
oten
tially
imp
orta
nt im
pro
vem
ents
in
pro
fess
iona
l pra
ctic
e. T
he e
ffect
iven
ess
of a
udit
and
feed
bac
k se
ems
to d
epen
d
on b
asel
ine
per
form
ance
and
how
the
feed
bac
k is
pro
vid
ed. F
utur
e st
udie
s of
aud
it an
d fe
edb
ack
shou
ld d
irect
ly c
omp
are
diff
eren
t w
ays
of p
rovi
din
g fe
edb
ack.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
8 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Gill
aize
au F
et
al92
Com
put
eris
ed a
dvi
ce
on d
rug
dos
age
to
imp
rove
pre
scrib
ing
pra
ctic
e
To a
sses
s w
heth
er c
omp
uter
ised
ad
vice
on
dru
g d
osag
e ha
s b
enefi
cial
effe
cts
on p
atie
nt o
utco
mes
co
mp
ared
with
rou
tine
care
(em
piri
c d
osin
g w
ithou
t co
mp
uter
ass
ista
nce)
.
We
incl
uded
RC
Ts, N
RC
Ts, C
BA
s an
d IT
S o
f com
put
eris
ed a
dvi
ce
on d
rug
dos
age.
The
par
ticip
ants
wer
e he
alth
care
pro
fess
iona
ls
resp
onsi
ble
for
pat
ient
car
e. T
he o
utco
mes
wer
e an
y ob
ject
ivel
y m
easu
red
cha
nge
in t
he h
ealth
of p
atie
nts
resu
lting
from
co
mp
uter
ised
ad
vice
(suc
h as
the
rap
eutic
dru
g co
ntro
l, cl
inic
al
imp
rove
men
t, a
dve
rse
reac
tions
).
Com
put
eris
ed a
dvi
ce fo
r d
rug
dos
age
can
ben
efit
peo
ple
tak
ing
cert
ain
dru
gs
com
par
ed w
ith e
mp
iric
dos
ing
(whe
re a
dos
e is
cho
sen
bas
ed o
n a
doc
tor'
s ob
serv
atio
ns a
nd e
xper
ienc
e) w
ithou
t co
mp
uter
ass
ista
nce.
Whe
n us
ing
the
com
put
er s
yste
m, h
ealth
care
pro
fess
iona
ls p
resc
ribed
ap
pro
pria
tely
hig
her
dos
es o
f the
dru
gs in
itial
ly fo
r am
inog
lyco
sid
e an
tibio
tics
and
the
cor
rect
dru
g d
ose
was
rea
ched
mor
e q
uick
ly fo
r or
al a
ntic
oagu
lant
s. It
sig
nific
antly
dec
reas
ed
thro
mb
oem
bol
ism
(blo
od c
lott
ing)
eve
nts
for
antic
oagu
lant
s an
d t
end
ed t
o re
duc
e un
wan
ted
effe
cts
for
amin
ogly
cosi
de
antib
iotic
s an
d a
ntire
ject
ion
dru
gs (a
lthou
gh n
ot
an im
por
tant
diff
eren
ce).
It te
nded
to
red
uce
the
leng
th o
f hos
pita
l sta
y co
mp
ared
w
ith r
outin
e ca
re w
ith c
omp
arab
le o
r b
ette
r co
st-e
ffect
iven
ess.
The
re w
as n
o ev
iden
ce o
f effe
cts
on d
eath
or
clin
ical
sid
e ev
ents
for
insu
lin (l
ow b
lood
sug
ar
(hyp
ogly
caem
ia)),
ana
esth
etic
age
nts,
ant
ireje
ctio
n d
rugs
(dru
gs t
aken
to
pre
vent
re
ject
ion
of a
tra
nsp
lant
ed o
rgan
) and
ant
idep
ress
ants
.
Alld
red
DP
et
al93
Inte
rven
tions
to
optim
ise
pre
scrib
ing
for
old
er p
eop
le in
car
e ho
mes
The
obje
ctiv
e of
the
rev
iew
was
to
det
erm
ine
the
effe
ct o
f int
erve
ntio
ns t
o op
timis
e ov
eral
l pre
scrib
ing
for
old
er p
eop
le li
ving
in c
are
hom
es.
We
incl
uded
RC
Ts e
valu
atin
g in
terv
entio
ns a
imed
at
optim
isin
g p
resc
ribin
g fo
r ol
der
peo
ple
(age
d 6
5 ye
ars
or o
lder
) liv
ing
in
inst
itutio
nalis
ed c
are
faci
litie
s. S
tud
ies
wer
e in
clud
ed if
the
y m
easu
red
one
or
mor
e of
the
follo
win
g p
rimar
y ou
tcom
es:
adve
rse
dru
g ev
ents
; hos
pita
l ad
mis
sion
s; m
orta
lity
or s
econ
dar
y ou
tcom
es, q
ualit
y of
life
(usi
ng v
alid
ated
inst
rum
ent);
med
icat
ion-
rela
ted
pro
ble
ms;
med
icat
ion
app
rop
riate
ness
(usi
ng v
alid
ated
in
stru
men
t); m
edic
ine
cost
s.
We
coul
d n
ot d
raw
rob
ust
conc
lusi
ons
from
the
evi
den
ce d
ue t
o va
riab
ility
in d
esig
n,
inte
rven
tions
, out
com
es a
nd r
esul
ts. T
he in
terv
entio
ns im
ple
men
ted
in t
he s
tud
ies
in t
his
revi
ew le
d t
o th
e id
entifi
catio
n an
d r
esol
utio
n of
med
icat
ion-
rela
ted
pro
ble
ms
and
imp
rove
men
ts in
med
icat
ion
app
rop
riate
ness
; how
ever
, evi
den
ce o
f a c
onsi
sten
t ef
fect
on
resi
den
t-re
late
d o
utco
mes
was
not
foun
d. T
here
is a
nee
d fo
r hi
gh-q
ualit
y C
RC
Ts t
estin
g cl
inic
al d
ecis
ion
sup
por
t sy
stem
s an
d m
ultid
isci
plin
ary
inte
rven
tions
th
at m
easu
re w
ell-
defi
ned
, im
por
tant
res
iden
t-re
late
d o
utco
mes
.
C: P
atie
nt s
atis
fact
ion
Bal
lini L
et
al33
Inte
rven
tions
to
red
uce
wai
ting
times
for
elec
tive
pro
ced
ures
To a
sses
s th
e ef
fect
iven
ess
of in
terv
entio
ns a
imed
at
red
ucin
g w
aitin
g tim
es fo
r el
ectiv
e ca
re, b
oth
dia
gnos
tic a
nd t
hera
peu
tic.
We
cons
ider
ed R
CTs
, CB
As
and
ITS
des
igns
tha
t m
et E
PO
C
min
imum
crit
eria
and
eva
luat
ed t
he e
ffect
iven
ess
of a
ny
inte
rven
tion
aim
ed a
t re
duc
ing
wai
ting
times
for
any
typ
e of
el
ectiv
e p
roce
dur
e. W
e co
nsid
ered
stu
die
s re
por
ting
one
or
mor
e of
the
follo
win
g ou
tcom
es: n
umb
er o
r p
rop
ortio
n of
p
artic
ipan
ts w
hose
wai
ting
times
wer
e ab
ove
or b
elow
a s
pec
ific
time
thre
shol
d, o
r p
artic
ipan
ts' m
ean
or m
edia
n w
aitin
g tim
es.
Com
par
ator
s co
uld
incl
ude
any
typ
e of
act
ive
inte
rven
tion
or
stan
dar
d p
ract
ice.
As
only
a h
and
ful o
f low
-qua
lity
stud
ies
are
pre
sent
ly a
vaila
ble
, we
cann
ot d
raw
any
fir
m c
oncl
usio
ns a
bou
t th
e ef
fect
iven
ess
of t
he e
valu
ated
inte
rven
tions
in r
educ
ing
wai
ting
times
. How
ever
, int
erve
ntio
ns in
volv
ing
the
pro
visi
on o
f mor
e ac
cess
ible
se
rvic
es (o
pen
acc
ess
or d
irect
boo
king
/ref
erra
l) sh
ow s
ome
pro
mis
e.
She
pep
rd S
et
al34
Hos
pita
l at
hom
e:
hom
e-b
ased
end
-of-
life
care
To d
eter
min
e if
pro
vid
ing
hom
e-b
ased
end
-of-
life
care
red
uces
the
like
lihoo
d o
f dyi
ng in
hos
pita
l and
w
hat
effe
ct t
his
has
on p
atie
nts'
sym
pto
ms,
qua
lity
of li
fe, h
ealth
ser
vice
cos
ts a
nd c
areg
iver
s, c
omp
ared
w
ith in
pat
ient
hos
pita
l or
hosp
ice
care
.
RC
Ts, i
nter
rup
ted
tim
e se
ries,
or
cont
rolle
d b
efor
e an
d a
fter
st
udie
s ev
alua
ting
the
effe
ctiv
enes
s of
hom
e-b
ased
end
-of-
life
care
with
inp
atie
nt h
osp
ital o
r ho
spic
e ca
re fo
r p
eop
le a
ged
18
yea
rs a
nd o
lder
.
The
evid
ence
incl
uded
in t
his
revi
ew s
upp
orts
the
use
of h
ome-
bas
ed e
nd-o
f-lif
e ca
re
pro
gram
mes
for
incr
easi
ng t
he n
umb
er o
f peo
ple
who
will
die
at
hom
e, a
lthou
gh t
he
num
ber
s of
peo
ple
ad
mitt
ed t
o ho
spita
l whi
le r
ecei
ving
end
-of-
life
care
sho
uld
be
mon
itore
d. F
utur
e re
sear
ch s
houl
d s
yste
mat
ical
ly a
sses
s th
e im
pac
t of
hom
e-b
ased
en
d-o
f-lif
e ca
re o
n ca
regi
vers
.
Dw
amen
a F
et a
l94In
terv
entio
ns fo
r p
rovi
der
s to
pro
mot
e a
pat
ient
-cen
tred
ap
pro
ach
in c
linic
al
cons
ulta
tions
To a
sses
s th
e ef
fect
s of
inte
rven
tions
for
heal
thca
re
pro
vid
ers
that
aim
to
pro
mot
e p
atie
nt-c
entr
ed c
are
app
roac
hes
in c
linic
al c
onsu
ltatio
ns.
In t
he o
rigin
al r
evie
w, s
tud
y d
esig
ns in
clud
ed R
CTs
, CC
Ts, C
BA
s an
d IT
S s
tud
ies
of in
terv
entio
ns fo
r he
alth
care
pro
vid
ers
that
p
rom
ote
pat
ient
-cen
tred
car
e in
clin
ical
con
sulta
tions
.
Inte
rven
tions
to
pro
mot
e p
atie
nt-c
entr
ed c
are
with
in c
linic
al c
onsu
ltatio
ns a
re
effe
ctiv
e ac
ross
stu
die
s in
tra
nsfe
rrin
g p
atie
nt-c
entr
ed s
kills
to
pro
vid
ers.
How
ever
, th
e ef
fect
s on
pat
ient
sat
isfa
ctio
n, h
ealth
beh
avio
ur a
nd h
ealth
sta
tus
are
mix
ed.
Ther
e is
som
e in
dic
atio
n th
at c
omp
lex
inte
rven
tions
dire
cted
at
pro
vid
ers
and
p
atie
nts
that
incl
ude
cond
ition
-sp
ecifi
c ed
ucat
iona
l mat
eria
ls h
ave
ben
efici
al e
ffect
s on
hea
lth b
ehav
iour
and
hea
lth s
tatu
s, o
utco
mes
not
ass
esse
d in
stu
die
s re
view
ed
pre
viou
sly.
The
latt
er c
oncl
usio
n is
ten
tativ
e at
thi
s tim
e an
d r
equi
res
mor
e d
ata.
Th
e he
tero
gene
ity o
f out
com
es, a
nd t
he u
se o
f sin
gle
item
con
sulta
tion
and
hea
lth
beh
avio
ur m
easu
res
limit
the
stre
ngth
of t
he c
oncl
usio
ns.
In t
he p
rese
nt u
pd
ate,
we
wer
e ab
le t
o lim
it th
e st
udie
s to
RC
Ts,
thus
lim
iting
the
like
lihoo
d o
f sam
plin
g er
ror.
This
is e
spec
ially
imp
orta
nt b
ecau
se t
he p
rovi
der
s w
ho v
olun
teer
fo
r st
udie
s of
pat
ient
-cen
tred
car
e m
etho
ds
are
likel
y to
be
diff
eren
t fr
om t
he g
ener
al p
opul
atio
n of
pro
vid
ers.
D:P
atie
nt a
nd c
areg
iver
eng
agem
ent
Léga
ré F
et
al37
Inte
rven
tions
for
imp
rovi
ng t
he
adop
tion
of s
hare
d
dec
isio
n m
akin
g (S
DM
) by
heal
thca
re
pro
fess
iona
ls
To d
eter
min
e th
e ef
fect
iven
ess
of in
terv
entio
ns t
o im
pro
ve h
ealth
care
pro
fess
iona
ls’ a
dop
tion
of S
DM
.R
CTs
and
NR
CTs
, CB
As
and
ITS
stu
die
s ev
alua
ting
inte
rven
tions
to
imp
rove
hea
lthca
re p
rofe
ssio
nals
' ad
optio
n of
SD
M w
here
the
p
rimar
y ou
tcom
es w
ere
eval
uate
d u
sing
ob
serv
er-b
ased
out
com
e m
easu
res
or p
atie
nt-r
epor
ted
out
com
e m
easu
res.
It is
unc
erta
in w
heth
er in
terv
entio
ns t
o im
pro
ve a
dop
tion
of S
DM
are
effe
ctiv
e gi
ven
the
low
qua
lity
of t
he e
vid
ence
. How
ever
, any
inte
rven
tion
that
act
ivel
y ta
rget
s p
atie
nts,
hea
lthca
re p
rofe
ssio
nals
or
bot
h, is
bet
ter
than
non
e. A
lso,
inte
rven
tions
ta
rget
ing
pat
ient
s an
d h
ealth
care
pro
fess
iona
ls t
oget
her
show
mor
e p
rom
ise
than
th
ose
targ
etin
g on
ly o
ne o
r th
e ot
her.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
9Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Sta
cey
et a
l38D
ecis
ion
aid
s fo
r p
eop
le fa
cing
hea
lth
trea
tmen
t or
scr
eeni
ng
dec
isio
ns
To a
sses
s th
e ef
fect
s of
dec
isio
n ai
ds
in p
eop
le
faci
ng t
reat
men
t or
scr
eeni
ng d
ecis
ions
.W
e in
clud
ed p
ublis
hed
RC
Ts c
omp
arin
g d
ecis
ion
aid
s w
ith
usua
l car
e an
d/o
r al
tern
ativ
e in
terv
entio
ns. F
or t
his
upd
ate,
we
excl
uded
stu
die
s co
mp
arin
g d
etai
led
vs
sim
ple
dec
isio
n ai
ds.
Com
par
ed w
ith u
sual
car
e ac
ross
a w
ide
varie
ty o
f dec
isio
n co
ntex
ts, p
eop
le
exp
osed
to
dec
isio
n ai
ds
feel
mor
e kn
owle
dge
able
, bet
ter
info
rmed
and
cle
arer
ab
out
thei
r va
lues
, and
the
y p
rob
ably
hav
e a
mor
e ac
tive
role
in d
ecis
ion
mak
ing
and
m
ore
accu
rate
ris
k p
erce
ptio
ns. T
here
is g
row
ing
evid
ence
tha
t d
ecis
ion
aid
s m
ay
imp
rove
val
ues-
cong
ruen
t ch
oice
s. T
here
are
no
adve
rse
effe
cts
on h
ealth
out
com
es
or s
atis
fact
ion.
New
for
this
up
dat
ed is
evi
den
ce in
dic
atin
g im
pro
ved
kno
wle
dge
and
ac
cura
te r
isk
per
cep
tions
whe
n d
ecis
ion
aid
s ar
e us
ed e
ither
with
in o
r in
pre
par
atio
n fo
r th
e co
nsul
tatio
n.
Cic
iriel
lo S
et
al95
Mul
timed
ia e
duc
atio
nal
inte
rven
tions
for
cons
umer
s ab
out
pre
scrib
ed a
nd
over
-the
-cou
nter
m
edic
atio
ns
To a
sses
s th
e ef
fect
s of
mul
timed
ia p
atie
nt e
duc
atio
n in
terv
entio
ns a
bou
t p
resc
ribed
and
ove
r-th
e-co
unte
r m
edic
atio
ns in
peo
ple
of a
ll ag
es, i
nclu
din
g ch
ildre
n an
d c
arer
s.
RC
Ts a
nd q
uasi
-RC
Ts o
f mul
timed
ia-b
ased
pat
ient
ed
ucat
ion
abou
t p
resc
ribed
or
over
-the
-cou
nter
med
icat
ions
in p
eop
le o
f all
ages
, inc
lud
ing
child
ren
and
car
ers,
if t
he in
terv
entio
n ha
d b
een
targ
eted
for
thei
r us
e.
We
foun
d t
hat
mul
timed
ia e
duc
atio
n p
rogr
amm
es a
bou
t m
edic
atio
ns a
re s
uper
ior
to n
o ed
ucat
ion
or e
duc
atio
n p
rovi
ded
as
par
t of
usu
al c
linic
al c
are
in im
pro
ving
p
atie
nt k
now
led
ge. T
here
was
wid
e va
riab
ility
in t
he r
esul
ts fr
om t
he s
ix s
tud
ies
that
com
par
ed m
ultim
edia
ed
ucat
ion
with
usu
al c
are
or n
o ed
ucat
ion.
How
ever
, al
l but
one
of t
he s
ix s
tud
ies
favo
ured
mul
timed
ia e
duc
atio
n. W
e al
so fo
und
tha
t m
ultim
edia
ed
ucat
ion
is s
uper
ior
to u
sual
car
e or
no
educ
atio
n in
imp
rovi
ng s
kill
leve
ls. T
he r
evie
w a
lso
sugg
este
d t
hat
mul
timed
ia w
as a
t le
ast
as e
ffect
ive
as o
ther
fo
rms
of e
duc
atio
n, in
clud
ing
writ
ten
educ
atio
n or
brie
f ed
ucat
ion
from
a h
ealth
p
rovi
der
. How
ever
, the
se fi
ndin
gs w
ere
bas
ed o
n a
smal
l num
ber
of s
tud
ies,
man
y of
whi
ch w
ere
of lo
w q
ualit
y. M
ultim
edia
ed
ucat
ion
did
not
imp
rove
com
plia
nce
with
m
edic
atio
ns (i
e, t
he d
egre
e to
whi
ch a
pat
ient
cor
rect
ly fo
llow
s ad
vice
ab
out
his
or
her
med
icat
ion)
com
par
ed w
ith u
sual
car
e or
no
educ
atio
n. W
e co
uld
not
det
erm
ine
the
effe
ct o
f mul
timed
ia e
duc
atio
n on
oth
er o
utco
mes
, suc
h as
pat
ient
sat
isfa
ctio
n,
self-
effic
acy
(con
fiden
ce in
the
ir ab
ility
to
per
form
hea
lth-r
elat
ed t
asks
) and
hea
lth
outc
omes
.
The
revi
ew fi
ndin
gs t
here
fore
sug
gest
s th
at m
ultim
edia
ed
ucat
ion
pro
gram
mes
ab
out
med
icat
ions
cou
ld b
e us
ed a
long
sid
e us
ual c
are
pro
vid
ed b
y he
alth
pro
vid
ers.
The
re
is n
ot e
noug
h ev
iden
ce t
o re
com
men
d it
as
a re
pla
cem
ent
for
writ
ten
educ
atio
n or
ed
ucat
ion
by
a he
alth
pro
fess
iona
l. M
ultim
edia
ed
ucat
ion
coul
d b
e us
ed in
stea
d
of d
etai
led
ed
ucat
ion
give
n b
y a
heal
th p
rovi
der
whe
n it
is n
ot p
ossi
ble
or
pra
ctic
al
for
heal
th p
rofe
ssio
nals
to
pro
vid
e th
is s
ervi
ce. T
his
revi
ew fo
und
tha
t th
ere
wer
e d
iffer
ence
s b
etw
een
the
typ
es o
f ed
ucat
ion
pro
vid
ed t
o th
e co
ntro
l gro
ups
and
wha
t re
sults
wer
e m
easu
red
. Thi
s lim
ited
the
ab
ility
to
sum
mar
ise
resu
lts a
cros
s st
udie
s,
so m
ost
of t
he c
oncl
usio
ns o
f thi
s re
view
wer
e b
ased
on
resu
lts fr
om a
sm
all n
umb
er
of s
tud
ies.
Mor
e st
udie
s of
mul
timed
ia e
duc
atio
nal p
rogr
amm
es a
re n
eed
ed t
o m
ake
the
resu
lts o
f thi
s re
view
mor
e re
liab
le.
E: C
ost
-eff
ecti
vene
ss h
ealt
h te
chno
log
y as
sess
men
t; c
ost
-eff
ecti
vene
ss, c
ost
-uti
lity
Ath
erto
n H
et
al96
Em
ail f
or c
linic
al
com
mun
icat
ion
bet
wee
n p
atie
nts/
care
give
rs a
nd
heal
thca
re
pro
fess
iona
ls
To a
sses
s th
e ef
fect
s of
hea
lthca
re p
rofe
ssio
nals
and
p
atie
nts
usin
g em
ail t
o co
mm
unic
ate
with
eac
h ot
her,
on p
atie
nt o
utco
mes
, hea
lth s
ervi
ce p
erfo
rman
ce,
serv
ice
effic
ienc
y an
d a
ccep
tab
ility
.
RC
Ts, q
uasi
-RC
Ts, C
BA
s an
d IT
S s
tud
ies
exam
inin
g in
terv
entio
ns
usin
g em
ail t
o al
low
pat
ient
s to
com
mun
icat
e cl
inic
al c
once
rns
to
a he
alth
care
pro
fess
iona
l and
rec
eive
a r
eply
, and
tak
ing
the
form
of
(1) u
nsec
ured
em
ail,
(2) s
ecur
e em
ail o
r (3
) web
mes
sagi
ng. A
ll he
alth
care
pro
fess
iona
ls, p
atie
nts
and
car
egiv
ers
in a
ll se
ttin
gs
wer
e co
nsid
ered
.
Eig
ht o
f the
tria
ls lo
oked
at
emai
l com
par
ed w
ith s
tand
ard
met
hod
s of
co
mm
unic
atio
n. W
here
em
ail w
as c
omp
ared
with
sta
ndar
d m
etho
ds
of
com
mun
icat
ion,
we
foun
d t
hat
we
coul
d n
ot p
rop
erly
det
erm
ine
wha
t ef
fect
em
ail
was
hav
ing
on p
atie
nt/c
areg
iver
out
com
es, a
s th
ere
wer
e m
issi
ng d
ata
and
the
re
sults
of t
he d
iffer
ent
stud
ies
varie
d. F
or h
ealth
ser
vice
use
out
com
es t
he s
ituat
ion
was
the
sam
e, b
ut s
ome
resu
lts s
eem
ed t
o sh
ow t
hat
an e
mai
l int
erve
ntio
n m
ay le
ad
to a
n in
crea
sed
num
ber
of e
mai
ls a
nd t
elep
hone
cal
ls b
eing
rec
eive
d b
y he
alth
care
p
rofe
ssio
nals
.
O
ne o
f the
tria
ls lo
oked
at
emai
l cou
nsel
ling
com
par
ed w
ith t
elep
hone
cou
nsel
ling.
W
e fo
und
tha
t it
only
look
ed a
t p
atie
nt o
utco
mes
, and
foun
d fe
w d
iffer
ence
s b
etw
een
grou
ps.
Whe
re t
here
wer
e d
iffer
ence
s, t
hese
sho
wed
tha
t te
lep
hone
cou
nsel
ling
lead
s to
gre
ater
cha
nges
in li
fest
yle
than
em
ail c
ouns
ellin
g.
Non
e of
the
tria
ls m
easu
red
how
em
ail a
ffect
s he
alth
care
pro
fess
iona
ls a
nd o
nly
one
mea
sure
d w
heth
er e
mai
l can
cau
se h
arm
. All
of t
he t
rials
wer
e b
iase
d in
som
e w
ay
and
whe
n w
e m
easu
red
the
qua
lity
of a
ll of
the
res
ults
we
foun
d t
hem
to
be
of lo
w o
r ve
ry lo
w q
ualit
y.
As
a re
sult
the
resu
lts o
f thi
s re
view
sho
uld
be
view
ed w
ith c
autio
n.
The
natu
re o
f the
res
ults
mea
ns t
hat
we
cann
ot m
ake
any
reco
mm
end
atio
ns fo
r ho
w
emai
l mig
ht b
est
be
used
in c
linic
al p
ract
ice.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
10 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
Aut
hor,
ref.
no
Tit
leO
bje
ctiv
esIn
clus
ion
crit
eria
Mai
n fi
ndin
gs
Flod
gren
G e
t al
82In
tera
ctiv
e te
lem
edic
ine
(TM
): ef
fect
s on
pro
fess
iona
l p
ract
ice
and
he
alth
care
out
com
es
To a
sses
s th
e ef
fect
iven
ess,
acc
epta
bili
ty a
nd c
osts
of
inte
ract
ive
TM a
s an
alte
rnat
ive
to, o
r in
ad
diti
on
to, u
sual
car
e (ie
, fac
e-to
-fac
e ca
re o
r te
lep
hone
co
nsul
tatio
n).
We
cons
ider
ed R
CTs
of i
nter
activ
e TM
tha
t in
volv
ed d
irect
p
atie
nt-p
rovi
der
inte
ract
ion
and
was
del
iver
ed in
ad
diti
on t
o, o
r su
bst
itutin
g fo
r, us
ual c
are
com
par
ed w
ith u
sual
car
e al
one,
to
par
ticip
ants
with
any
clin
ical
con
diti
on. W
e ex
clud
ed t
elep
hone
on
ly in
terv
entio
ns a
nd w
holly
aut
omat
ic s
elf-
man
agem
ent
TM
inte
rven
tions
.
The
find
ings
in o
ur r
evie
w in
dic
ate
that
the
use
of T
M in
the
man
agem
ent
of h
eart
fa
ilure
ap
pea
rs t
o le
ad t
o si
mila
r he
alth
out
com
es a
s fa
ce-t
o-fa
ce o
r te
lep
hone
d
eliv
ery
of c
are;
the
re is
evi
den
ce t
hat
TM c
an im
pro
ve t
he c
ontr
ol o
f blo
od g
luco
se
in t
hose
with
dia
bet
es.
The
cost
to
a he
alth
ser
vice
, and
acc
epta
bili
ty b
y p
atie
nts
and
hea
lthca
re
pro
fess
iona
ls, i
s no
t cl
ear
due
to
limite
d d
ata
rep
orte
d fo
r th
ese
outc
omes
. The
ef
fect
iven
ess
of T
M m
ay d
epen
d o
n a
num
ber
of d
iffer
ent
fact
ors,
incl
udin
g th
ose
rela
ted
to
the
stud
y p
opul
atio
n, e
g, t
he s
ever
ity o
f the
con
diti
on a
nd t
he d
isea
se
traj
ecto
ry o
f the
par
ticip
ants
, the
func
tion
of t
he in
terv
entio
n, e
g, if
it is
use
d fo
r m
onito
ring
a ch
roni
c co
nditi
on, o
r to
pro
vid
e ac
cess
to
dia
gnos
tic s
ervi
ces,
as
wel
l as
the
heal
thca
re p
rovi
der
and
hea
lthca
re s
yste
m in
volv
ed in
del
iver
ing
the
inte
rven
tion.
Wee
ks G
et
al97
Non
-med
ical
p
resc
ribin
g vs
med
ical
p
resc
ribin
g fo
r ac
ute
and
chr
onic
dis
ease
m
anag
emen
t in
p
rimar
y an
d s
econ
dar
y ca
re
To a
sses
s cl
inic
al, p
atie
nt-r
epor
ted
and
res
ourc
e us
e ou
tcom
es o
f non
-med
ical
pre
scrib
ing
for
man
agin
g ac
ute
and
chr
onic
hea
lth c
ond
ition
s in
prim
ary
and
se
cond
ary
care
set
tings
com
par
ed w
ith m
edic
al
pre
scrib
ing
(usu
al c
are)
.
RC
Ts, C
RC
Ts, C
BA
s (w
ith a
t le
ast
two
inte
rven
tion
and
tw
o co
ntro
l site
s) a
nd IT
S (w
ith a
t le
ast
thre
e ob
serv
atio
ns b
efor
e an
d
afte
r th
e in
terv
entio
n) c
omp
arin
g: (1
) non
-med
ical
pre
scrib
ing
vs
med
ical
pre
scrib
ing
in a
cute
car
e; (2
) non
-med
ical
pre
scrib
ing
vs
med
ical
pre
scrib
ing
in c
hron
ic c
are;
(3) n
on-m
edic
al p
resc
ribin
g vs
med
ical
pre
scrib
ing
in s
econ
dar
y ca
re; (
4) n
on-m
edic
al
pre
scrib
ing
vs m
edic
al p
resc
ribin
g in
prim
ary
care
; (5)
com
par
ison
s b
etw
een
diff
eren
t no
n-m
edic
al p
resc
riber
gr
oup
s an
d (6
) non
-med
ical
hea
lthca
re p
rovi
der
s w
ith fo
rmal
p
resc
ribin
g tr
aini
ng v
s th
ose
with
out
form
al p
resc
ribin
g tr
aini
ng.
The
find
ings
sug
gest
tha
t no
n-m
edic
al p
resc
riber
s, p
ract
isin
g w
ith v
aryi
ng b
ut h
igh
leve
ls o
f pre
scrib
ing
auto
nom
y, in
a r
ange
of s
ettin
gs, w
ere
as e
ffect
ive
as u
sual
car
e m
edic
al p
resc
riber
s. N
on-m
edic
al p
resc
riber
s ca
n d
eliv
er c
omp
arab
le o
utco
mes
for
syst
olic
blo
od p
ress
ure,
gly
cate
d h
aem
oglo
bin
, low
-den
sity
lip
opro
tein
, med
icat
ion
adhe
renc
e, p
atie
nt s
atis
fact
ion
and
hea
lth-r
elat
ed q
ualit
y of
life
.
It w
as d
ifficu
lt to
det
erm
ine
the
imp
act
of n
on-m
edic
al p
resc
ribin
g co
mp
ared
with
m
edic
al p
resc
ribin
g fo
r ad
vers
e ev
ents
and
res
ourc
e us
e ou
tcom
es d
ue t
o th
e in
cons
iste
ncy
and
var
iab
ility
in r
epor
ting
acro
ss s
tud
ies.
F: L
ead
ersh
ip, v
alue
s, v
isio
n
Flod
gren
G e
t al
98Lo
cal o
pin
ion
lead
ers:
ef
fect
s on
pro
fess
iona
l p
ract
ice
and
he
alth
care
out
com
es
To a
sses
s th
e ef
fect
iven
ess
of t
he u
se o
f loc
al
opin
ion
lead
ers
in im
pro
ving
pro
fess
iona
l pra
ctic
e an
d p
atie
nt o
utco
mes
.
Stu
die
s el
igib
le fo
r in
clus
ion
wer
e R
CTs
inve
stig
atin
g th
e ef
fect
iven
ess
of u
sing
op
inio
n le
ader
s to
dis
sem
inat
e ev
iden
ce-
bas
ed p
ract
ice
and
rep
ortin
g ob
ject
ive
mea
sure
s of
pro
fess
iona
l p
erfo
rman
ce a
nd/o
r he
alth
out
com
es.
Op
inio
n le
ader
s al
one
or in
com
bin
atio
n w
ith o
ther
inte
rven
tions
may
suc
cess
fully
p
rom
ote
evid
ence
-bas
ed p
ract
ice,
but
effe
ctiv
enes
s va
ries
bot
h w
ithin
and
bet
wee
n st
udie
s. T
hese
res
ults
are
bas
ed o
n he
tero
gene
ous
stud
ies
diff
erin
g in
ter
ms
of t
ype
of in
terv
entio
n, s
ettin
g an
d o
utco
mes
mea
sure
d. I
n m
ost
of t
he s
tud
ies,
the
rol
e of
th
e op
inio
n le
ader
was
not
cle
arly
des
crib
ed, a
nd it
is t
here
fore
not
pos
sib
le t
o sa
y w
hat
the
bes
t w
ay is
to
optim
ise
the
effe
ctiv
enes
s of
op
inio
n le
ader
s.
Gre
en C
J e
t al
99P
harm
aceu
tical
p
olic
ies:
effe
cts
of r
estr
ictio
ns o
n re
imb
urse
men
t
To d
eter
min
e th
e ef
fect
s of
a p
harm
aceu
tical
p
olic
y re
stric
ting
the
reim
bur
sem
ent
of s
elec
ted
m
edic
atio
ns o
n d
rug
use,
hea
lthca
re u
tilis
atio
n,
heal
th o
utco
mes
and
cos
ts (e
xpen
ditu
res)
.
Incl
uded
wer
e st
udie
s of
pha
rmac
eutic
al p
olic
ies
that
res
tric
t co
vera
ge a
nd r
eim
bur
sem
ent
of s
elec
ted
dru
gs o
r d
rug
clas
ses,
of
ten
usin
g ad
diti
onal
pat
ient
-sp
ecifi
c in
form
atio
n re
late
d t
o he
alth
sta
tus
or n
eed
. We
incl
uded
RC
Ts, N
RC
Ts, I
TS a
naly
ses,
R
MS
and
CB
As
set
in la
rge
care
sys
tem
s or
juris
dic
tions
.
Imp
lem
entin
g re
stric
tions
to
cove
rage
and
rei
mb
urse
men
t of
sel
ecte
d m
edic
atio
ns
can
dec
reas
e th
ird-p
arty
dru
g sp
end
ing
with
out
incr
easi
ng t
he u
se o
f oth
er h
ealth
se
rvic
es (s
ix s
tud
ies)
. Rel
axin
g re
imb
urse
men
t ru
les
for
dru
gs u
sed
for
seco
ndar
y p
reve
ntio
n ca
n al
so r
emov
e b
arrie
rs t
o ac
cess
. Pol
icy
des
ign,
how
ever
, nee
ds
to b
e b
ased
on
rese
arch
qua
ntify
ing
the
harm
and
ben
efit
pro
files
of t
arge
t an
d a
ltern
ativ
e d
rugs
to
avoi
d u
nwan
ted
hea
lth s
yste
m a
nd h
ealth
effe
cts.
Hea
lth im
pac
t ev
alua
tion
shou
ld b
e co
nduc
ted
whe
re d
rugs
are
not
inte
rcha
ngea
ble
. Im
pac
ts o
n he
alth
eq
uity
, re
latin
g to
the
fair
and
just
dis
trib
utio
n of
hea
lth b
enefi
ts in
soc
iety
(eg,
sus
tain
able
ac
cess
to
pub
licly
fina
nced
dru
g b
enefi
ts fo
r se
nior
s an
d lo
w-i
ncom
e p
opul
atio
ns),
also
req
uire
exp
licit
mea
sure
men
t.
Jia
L et
al10
0S
trat
egie
s fo
r ex
pan
din
g he
alth
in
sura
nce
cove
rage
in
vuln
erab
le p
opul
atio
ns
To a
sses
s th
e ef
fect
iven
ess
of s
trat
egie
s fo
r ex
pan
din
g he
alth
insu
ranc
e co
vera
ge in
vul
nera
ble
p
opul
atio
ns.
RC
Ts, N
RC
Ts, C
BA
s an
d IT
S s
tud
ies
that
eva
luat
ed t
he e
ffect
s of
st
rate
gies
on
incr
easi
ng h
ealth
insu
ranc
e co
vera
ge fo
r vu
lner
able
p
opul
atio
ns. W
e d
efine
d s
trat
egie
s as
mea
sure
s to
imp
rove
th
e en
rolm
ent
of v
ulne
rab
le p
opul
atio
ns in
to h
ealth
insu
ranc
e sc
hem
es. T
wo
cate
gorie
s an
d s
ix s
pec
ified
str
ateg
ies
wer
e id
entifi
ed a
s th
e in
terv
entio
ns.
Com
mun
ity-b
ased
cas
e m
anag
ers
who
pro
vid
e he
alth
insu
ranc
e in
form
atio
n,
app
licat
ion
sup
por
t an
d n
egot
iate
with
the
insu
rer
pro
bab
ly in
crea
se e
nrol
men
t of
ch
ildre
n in
hea
lth in
sura
nce
sche
mes
. How
ever
, the
tra
nsfe
rab
ility
of t
his
inte
rven
tion
to o
ther
pop
ulat
ions
or
othe
r se
ttin
gs is
unc
erta
in. H
and
ing
out
insu
ranc
e ap
plic
atio
n m
ater
ials
in h
osp
ital e
mer
genc
y d
epar
tmen
ts m
ay h
elp
incr
ease
the
enr
olm
ent
of
child
ren
in h
ealth
insu
ranc
e sc
hem
es. F
urth
er s
tud
ies
eval
uatin
g th
e ef
fect
iven
ess
of
diff
eren
t st
rate
gies
for
exp
and
ing
heal
th in
sura
nce
cove
rage
in v
ulne
rab
le p
opul
atio
n ar
e ne
eded
in d
iffer
ent
sett
ings
, with
car
eful
att
entio
n gi
ven
to s
tud
y d
esig
n.
G: I
nteg
rati
on
Ree
ves
S e
t al
42In
terp
rofe
ssio
nal
colla
bor
atio
n (IP
C) t
o im
pro
ve p
rofe
ssio
nal
pra
ctic
e an
d
heal
thca
re o
utco
mes
To a
sses
s th
e im
pac
t of
pra
ctic
e-b
ased
inte
rven
tions
d
esig
ned
to
imp
rove
IPC
am
ong
heal
thca
re a
nd
soci
al c
are
pro
fess
iona
ls, c
omp
ared
with
usu
al c
are
or t
o an
alte
rnat
ive
inte
rven
tion,
on
at le
ast
one
of t
he fo
llow
ing
prim
ary
outc
omes
: pat
ient
hea
lth
outc
omes
, clin
ical
pro
cess
or
effic
ienc
y ou
tcom
es o
r se
cond
ary
outc
omes
(col
lab
orat
ive
beh
avio
ur).
We
incl
uded
ran
dom
ised
tria
ls o
f pra
ctic
e-b
ased
IPC
in
terv
entio
ns in
volv
ing
heal
th a
nd s
ocia
l car
e p
rofe
ssio
nals
co
mp
ared
with
usu
al c
are
or t
o an
alte
rnat
ive
inte
rven
tion.
Giv
en t
hat
the
cert
aint
y of
evi
den
ce fr
om t
he in
clud
ed s
tud
ies
was
jud
ged
to
be
low
to
very
low
, the
re is
not
suf
ficie
nt e
vid
ence
to
dra
w c
lear
con
clus
ions
on
the
effe
cts
of IP
C in
terv
entio
ns. N
ever
thel
ess,
due
to
the
diffi
culti
es h
ealth
pro
fess
iona
ls
enco
unte
r w
hen
colla
bor
atin
g in
clin
ical
pra
ctic
e, it
is e
ncou
ragi
ng t
hat
rese
arch
on
the
num
ber
of i
nter
vent
ions
to
imp
rove
IPC
has
incr
ease
d s
ince
thi
s re
view
w
as la
st u
pd
ated
. Whi
le t
his
field
is d
evel
opin
g, fu
rthe
r rig
orou
s, m
ixed
-met
hod
st
udie
s ar
e re
qui
red
. Fut
ure
stud
ies
shou
ld fo
cus
on lo
nger
acc
limat
isat
ion
per
iod
s b
efor
e ev
alua
ting
new
ly im
ple
men
ted
IPC
inte
rven
tions
, and
use
long
er fo
llow
-up
to
gene
rate
a m
ore
info
rmed
und
erst
and
ing
of t
he e
ffect
s of
IPC
on
clin
ical
pra
ctic
e.
Tab
le 1
C
ontin
ued
Con
tinue
d
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
11Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
self-management programmes were generally effective in improving the use of medicines, adherence to prescrip-tions, reducing adverse events and improving clinical outcomes. It also found a lower mortality rate among people self-managing their antithrombotic therapy.30 The same review revealed numerous other promising inter-ventions to improve adherence and other key outcomes related to medicine usage (table 1B).
Patient satisfactionPatient satisfaction is fundamental in the case of patients with chronic disease who are likely to be involved in a lasting relationship with healthcare services. It is linked to patients’ expectations of ideal care and their actual expe-rience of care,32 and it is considered by most as a multidi-mensional construct including multiple domains such as accessibility, organisational characteristics of the system, clinical and communication skills and the doctor-patient relationship, among others. Long waiting lists for non-ur-gent health procedures are quite common and may affect the health professional-patient relationship, causing distress for patients and their caregivers and distrust of the healthcare system. Improving access by implementing an open access or direct booking for some health prob-lems or referrals has been shown to improve patient satis-faction.33 Home-based interventions for end-of-life care have also been shown to improve both patient and care-givers satisfaction34 (table 1C).
Patient and caregiver engagement refers to a patient-cen-tred and family centred collaborative approach that is tailored to match the fundamental realities of chronic care. Patient and caregiver engagement helps patients discover and develop their inherent capacity to take responsibility for their own life.35 Empowering patients by providing information and increasing their contribu-tion to the planning of services can greatly influence the development of clinical governance on clinical processes and on organisational matters. Contributions from patients will affect the responsiveness and performance of healthcare services, and the process by means of which quality improvement initiatives are identified and priori-tised.36 Recent reviews of interventions promoting shared medical decision making, with active involvement of both patients and health professionals, have found moderate evidence of better patient involvement. In addition, deci-sion aids (pamphlets, videos or video-based tools) may improve patient’s knowledge of their care options, so they feel more informed and better able to participate in deci-sion making37 38 (table 1D).
Health technology assessment (HTA) refers to the system-atic assessment of the properties and effects of a health technology, addressing the direct and intended effects of the technology, as well as its indirect and unintended consequences. The main aims of HTA are to inform deci-sion-making regarding health technologies (bearing in mind the finite resources available), to drive the intro-duction of innovations and to identify ineffective or harmful technologies.39 Whether it involves introducing A
utho
r, re
f. n
oT
itle
Ob
ject
ives
Incl
usio
n cr
iter
iaM
ain
find
ing
s
Sm
ith S
M e
t al
101
Sha
red
car
e ac
ross
th
e in
terf
ace
bet
wee
n p
rimar
y an
d s
pec
ialty
ca
re in
man
agem
ent
of
long
-ter
m c
ond
ition
s
To d
eter
min
e th
e ef
fect
iven
ess
of s
hare
d c
are
heal
th s
ervi
ce in
terv
entio
ns d
esig
ned
to
imp
rove
the
m
anag
emen
t of
chr
onic
dis
ease
acr
oss
the
prim
ary/
spec
ialty
car
e in
terf
ace.
We
cons
ider
ed R
CTs
, NR
CTs
, CB
As
and
ITS
eva
luat
ing
the
effe
ctiv
enes
s of
sha
red
car
e in
terv
entio
ns fo
r p
eop
le w
ith
chro
nic
cond
ition
s in
prim
ary
care
and
com
mun
ity s
ettin
gs. T
he
inte
rven
tion
was
com
par
ed w
ith u
sual
car
e in
tha
t se
ttin
g.
This
rev
iew
sug
gest
s th
at s
hare
d c
are
is e
ffect
ive
for
man
agin
g d
epre
ssio
n. S
hare
d
care
inte
rven
tions
for
othe
r co
nditi
ons
shou
ld b
e d
evel
oped
with
in r
esea
rch
sett
ings
, so
tha
t fu
rthe
r ev
iden
ce c
an b
e co
nsid
ered
bef
ore
they
are
intr
oduc
ed r
outin
ely
into
he
alth
sys
tem
s.
Hay
es S
L et
al10
2C
olla
bor
atio
n b
etw
een
loca
l hea
lth a
nd lo
cal
gove
rnm
ent
agen
cies
fo
r he
alth
imp
rove
men
t
To e
valu
ate
the
effe
cts
of in
tera
genc
y co
llab
orat
ion
bet
wee
n lo
cal h
ealth
and
loca
l gov
ernm
ent
agen
cies
on
hea
lth o
utco
mes
in a
ny p
opul
atio
n or
age
gro
up.
RC
Ts, C
CTs
, CB
As
and
ITS
whe
re t
he s
tud
y re
por
ted
ind
ivid
ual
heal
th o
utco
mes
aris
ing
from
inte
rage
ncy
colla
bor
atio
n b
etw
een
heal
th a
nd lo
cal g
over
nmen
t ag
enci
es c
omp
ared
with
sta
ndar
d
care
. Stu
die
s w
ere
sele
cted
ind
epen
den
tly in
dup
licat
e, w
ith n
o re
stric
tion
on p
opul
atio
n su
bgr
oup
or
dis
ease
.
Col
lab
orat
ion
bet
wee
n lo
cal h
ealth
and
loca
l gov
ernm
ent
is c
omm
only
con
sid
ered
b
est
pra
ctic
e. H
owev
er, t
he r
evie
w d
id n
ot id
entif
y an
y re
liab
le e
vid
ence
tha
t in
tera
genc
y co
llab
orat
ion,
com
par
ed w
ith s
tand
ard
ser
vice
s, n
eces
saril
y le
ads
to
heal
th im
pro
vem
ent.
A fe
w s
tud
ies
iden
tified
com
pon
ent
ben
efits
but
the
se w
ere
not
refle
cted
in o
vera
ll ou
tcom
e sc
ores
and
cou
ld h
ave
resu
lted
from
the
use
of
sign
ifica
nt a
dd
ition
al r
esou
rces
. Alth
ough
age
ncie
s ap
pea
r en
thus
iast
ic a
bou
t co
llab
orat
ion,
diffi
culti
es in
the
prim
ary
stud
ies
and
inco
mp
lete
imp
lem
enta
tion
of in
itiat
ives
hav
e p
reve
nted
the
dev
elop
men
t of
a s
tron
g ev
iden
ce b
ase.
If t
hese
w
eakn
esse
s ar
e ad
dre
ssed
in fu
ture
stu
die
s (e
g, b
y p
rovi
din
g gr
eate
r d
etai
l on
the
imp
lem
enta
tion
of p
rogr
amm
es; u
sing
mor
e ro
bus
t d
esig
ns, i
nteg
rate
d p
roce
ss
eval
uatio
ns t
o sh
ow h
ow w
ell t
he p
artn
ers
of t
he c
olla
bor
atio
n w
orke
d t
oget
her
and
m
easu
rem
ent
of h
ealth
out
com
es),
it co
uld
pro
vid
e a
bet
ter
und
erst
and
ing
of w
hat
mig
ht w
ork
and
why
. It
is p
ossi
ble
tha
t lo
cal c
olla
bor
ativ
e p
artn
ersh
ips
del
iver
ing
envi
ronm
enta
l int
erve
ntio
ns m
ay r
esul
t in
hea
lth g
ain
but
the
evi
den
ce b
ase
for
this
is
ver
y lim
ited
. Eva
luat
ions
of i
nter
agen
cy c
olla
bor
ativ
e ar
rang
emen
ts fa
ce m
any
chal
leng
es. T
he r
esul
ts d
emon
stra
te t
hat
colla
bor
ativ
e co
mm
unity
par
tner
ship
s ca
n b
e es
tab
lishe
d t
o d
eliv
er in
terv
entio
ns b
ut it
is im
por
tant
to
agre
e go
als,
met
hod
s of
wor
king
, mon
itorin
g an
d e
valu
atio
n b
efor
e im
ple
men
tatio
n to
pro
tect
pro
gram
me
fidel
ity a
nd in
crea
se t
he p
oten
tial f
or e
ffect
iven
ess.
CP
G, c
linic
al p
ract
ice
guid
elin
e; C
WA
, col
lab
orat
ive
writ
ing
app
licat
ions
.
Tab
le 1
C
ontin
ued
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
12 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
electrostimulators for treating incontinence, or disin-vesting in old medical ventilators for long-term domicil-iary respiratory support, or a new clinical pathway for diabetes, HTA is a robust method for orienting deci-sion-makers and clinicians towards the best available choices (table 1E).
the atmosphereThe atmosphere dimensions defined at this level shape the interventions given to patients, as petal dimensions, and describe activities between professionals inside the organisation, as well as the relationship with the civil society. Dimensions of the atmosphere include vision and values, integrated care and accountability.
A well-led organisation will monitor whether the vision and values of clinical governance are being clearly and effectively communicated to all members of the staff. This communication gives staff a common and consistent purpose, and clear expectations. A clear vision engenders an open-minded and questioning culture, and ensures that both the ethos and the day-to-day delivery of clin-ical governance remain an integral part of every clinical service. Apart from health system issues, one of the major barriers to the successful transfer of evidence into locally accepted policies lies in ineffective and unaccountable leaders and managers40 (table 1F).
Integrated care is a concept that brings together the inputs, delivery, management and organisation of services related to patients’ diagnosis, treatment, care, rehabilitation and health promotion. As individuals move across healthcare settings and services, the model of care requires integration and cooperation between a multiplicity of professionals. This integration and coop-eration demands a high degree of collaboration between healthcare professionals involved in these services, as well as organisational support. This integration should operate within a primary care system, and through effec-tive communications between specialist and primary care providers, to guarantee better transitions of care for patients with chronic disease. The latter has significant positive effects in reducing hospital readmissions and mortality41–43 (table 1G).
A robust, comprehensive and transparent accountability, with measurement of performance in healthcare activi-ties can ensure that the system is accountable to society at large, to health professionals and others involved in deliv-ering care and to patients. A fundamental shift is needed from a demand-driven model valuing the volume of the production, to a new model where the providers are accountable for the care outcomes and value that matter to patients and the broader population. Driving account-ability for outcomes and value leads to several key bene-fits: it encourages innovation along entire care pathways, to raise quality and reduce cost; it incentivises collabo-ration between providers to coordinate care to deliver outcomes; it clarifies for policy-makers what is being achieved by the money being spent and it gives people a stronger voice in their own care and in defining what
matters.44 45 Such a system can support effective auditing, which can improve care processes in health districts over the long term.45
the stem defines the means to reach the petalsIt is also important to ensure that key underpinning strategies (such as information technology, education and training, research and dissemination) support the delivery system to reach the defined petals dimensions. For example, any service re-organisation should involve building better information communication and tech-nology systems, to enable a better exchange of infor-mation throughout a newly rearranged organisation. An effective workforce also needs appropriate technical support, such as access to valid best evidence, to support its clinical decisions. To be useful, the data in informa-tion systems must be valid, up-to-date and presented in a way that offers insight. It should also be integrated with the electronic health record, and not provide excessive alerts that lead to ‘alert fatigue’. Finally, it should focus on research that provides evidence of improved patient-ori-ented outcomes, rather than disease or surrogate markers of improvement.46
Data to highlight differences in patient outcomes, shortfalls in standards, comparisons with other services and time trends are essential. Interconnected electronic health records support clinicians’ efforts to improve outcomes across the full continuum of care, while ensuring accountability, engaging patients in making decisions and managing their care, improving safety and care coordination and avoiding any waste of resources.47 Data are essential to managing performance, normally in relation to two subsets of activities: performance evalua-tion and performance improvement. Both make use of indicators for assessment purposes, and the latter also to monitor a healthcare organisation’s performance during an improvement process.48 For patients with multiple chronic conditions, it is also necessary to devise team indicators and indicators that encompass all the care provided to a given patient.
Improving the training of healthcare professionals will be important in any effort to re-organise a healthcare system. For example, if more nurses are going to take on the role of case study managers, they will need additional training to build their skill base.49 Ideally, continuing professional education should not be limited to updating professionals’ technical skills, knowledge of new research and improved clinical decision-making. In addition, it should enable all members of the staff to develop skills that allow them to practice to the maximum of their training, and to assure that their skills are aligned with the organisation's objectives.
the earth defines the ground where primary care is deliveredCommunity participation should be part of health-care service planning and evaluation. It is also essential to mobilise community resources to meet the needs of people with long-term conditions, creating a culture and
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
13Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
mechanisms that promote safe, good-quality care. It has been suggested that positive outcomes for people with long-term conditions are only achieved when individuals and their families and community partners are informed, motivated and work together.50 Families and individuals are then supported by the broader community, which in turn influences the broader policy environment, and vice versa. In this model, integrated policies span different types of disease and prevention strategies, consistent financing, the development of human resources, legisla-tive frameworks and partnerships.
dIsCussIOnA framework for clinical governance promotes an inte-grated effort to bring together all relevant activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach, and thus sustain the provision of better care for patients with chronic disease and multimorbidity.
Quality assuranceThere are numerous challenges to providing coordi-nated and high-quality primary care to patients with chronic disease. For instance, the quality of the manage-ment of patients with multiple chronic conditions should be examined, taking the completeness of care into account.51 52 There is often a lengthy gap between the generation of new research-based evidence and the application of this evidence in clinical practice. This is true for clinical management, and for organisational management of patients. Knowledge management is achieved by creating, sharing and applying knowledge, as well as through feeding the valuable lessons learnt and best practices into the ‘corporate memory’ to foster continued organisational learning.51 This broad remit of knowledge management and the sharing of knowl-edge among organisational fields includes developing values, structures and information technology. It places emphasis on how value can be added: the petals should be revitalised by the atmosphere and ground. Moreover, quality assurance in patients with chronic illness implies using measures to assess the impact of interventions for chronic conditions on a patient’s daily functioning and quality of life. A number of measures from the Medical Outcomes Study have been used in studies of multimor-bidity in primary healthcare.53 An advantage of using such measures for patients with multimorbidity lies in that it does not focus on the care provided for specific diseases. Overuse of healthcare has also been assessed by examining hospitalisation rates for ambulatory care sensi-tive conditions, that is, conditions for which it is believed that well-organised delivery of high-quality primary care services can prevent the need for hospitalisation.54 55 Overuse of healthcare has also been measured in terms of the frequency of hospitalisation and emergency depart-ment attendance for patients with multiple morbidities.56 These measures are not disease-specific, so they could
be used to assess overall quality of care for patients with multiple health problems. One of the main challenges, which takes a different form in each context, is to develop appropriate incentives that promote and encourage a collective commitment to this alternative paradigm of continuous performance improvement.57 The organi-sational leadership should maintain the organisation’s focus on the use of information for improvement rather than sanction or punishment. This involves being able to establish a trusting and working relationship with the potential users, and to move away from a controlling or paternalistic approach.
Client satisfactionAn important consequence of how care of patients with chronic disease is managed relates to perceived quality or satisfaction, which itself is associated with the health of the population as a whole.32 Patient satisfaction is associated with clinical outcomes, patient retention and medical malpractice claims, so it is a proxy, but nonethe-less is a very effective indicator of the success of a primary care system. Different tools have been developed to assess perceived health quality for chronic diseases. A recent European project58 focused on perceptions of quality in primary healthcare in seven countries, highlighting the natural impact of waiting time on patient satisfaction, and the more complex association between equity and access to primary healthcare services. There is strong evidence that one of the most important determinants affecting satisfaction with health services is the patient-practitioner relationship, including the information the former receives from the latter.59 This is a crucial issue in the long-term management of chronic conditions. Different conceptual frameworks have been created to under-stand patient satisfaction, which is recognised as a crit-ical issue to developing service improvement strategies. For example, Dagger et al32 have proposed service quality as a multidimensional, higher order construct, with four overarching dimensions (interpersonal quality, technical quality, environment quality and administrative quality) and nine subdimensions. They suggest that consumers assess service quality at a global level, a dimensional level and at a subdimensional level, with each level influencing perceptions at the level above.
Patient activation and self-managementThe evidence linking patient activation, including person’s beliefs, motivation and actions for self-care, with health outcomes, the patient experience and cost has grown substantially over the past decade.60 Higher acti-vation levels in chronically ill patients are associated with higher levels of adherence to treatments, self-monitoring of conditions and regular chronic care. Patient activation to enhance patients' skills, knowledge and confidence in their ability to take healthy action and manage their disease should therefore be one of the main goals of a primary care health system. Patient activation can increase the motivation for self-management for chronic diseases,
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
14 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
such as creating durable healthy lifestyle changes and improving adherence to treatment recommendations. In this respect, self-management reaches beyond traditional disease management by incorporating the wider concept of prevention, emphasising the notion that people who are chronically ill still need preventive services to promote their wellness and mitigate any further deterioration of their health. Self-management is consequently an excel-lent way to address chronic conditions as a major public health issue.61 Researchers have also placed a strong emphasis on the crucial role of family in patient self-man-agement, recognising that enhancing families’ self-man-agement generates better health outcomes.62 Despite its important beneficial effects, many factors threaten effec-tive empowerment, including individual patient charac-teristics, poor technological or IT infrastructure, poor educational or communications strategies and commu-nication and language barriers between healthcare providers and patients.
Performance monitoringWhere performance monitoring systems are adopted as a management approach, performance tends to be better than when such systems are not in place. Reverse causality could be argued, higher quality primary care organisations may be more likely to implement perfor-mance evaluation. Healthcare professionals are gener-ally keen to measure, know and demonstrate that they are making an important difference for their patients. Although there is little evidence of its effect on health outcomes or overall value for money,63 64 the emphasis on performance management in primary care is growing. A recent report highlighted how performance management is influenced by its own understanding, the systems used and the evaluator-evaluated relation-ship.48 Performance management needs an appropriate set of valid of indicators relevant to primary care prac-tice that recognise the complexities of different clinical pathways, multimorbidity, educational and counselling activities, goals and other activities typical in primary care.65
An example of such indicators was identified by the Australian Institute of Primary Care,66 which classified them as discipline-specific, disease-specific or systemic; these indicators could effectively inform primary care governance. Where instances of poor quality were not assessed, the management was to be ineffective, staff concerns about standards of care were marginalised or worse, adequate improvement systems were not in place and the service was not seen through the patients’ eyes. Clinical pathways are quite popular as a format for trans-lating guidelines into practice and facilitating an inte-grated approach to care that is supported by scientific evidence, but is also respectful of organisational issues. These pathways design an optimal pathway (or series of pathways) for managing clinical problems within a healthcare organisation. Their development engages all of the professionals responsible for managing the
disease or problem, and provides an opportunity to establish clinical and organisational indicators, and to define information flows. Certainly, the management of multiple conditions using clinical pathways requires a comprehensive approach that should consider many aspects, such as establishing the patient’s priorities, eval-uating the disease and treatment burdens and having a discussion of the benefits and risks of specific interven-tions. As part of the patient-health professional relation-ship, the individualised management plan constitutes the foundation of a shared explicit decision-making process. It is a written agreement that includes all rele-vant decisions, such as starting or stopping a treatment, anticipating the possible disease evolution and future healthcare appointments. It should assign responsibility for processes and interventions to specific health profes-sionals, to ensure appropriate communication with the patient and caregivers, and with other providers.67 68
Clinical risk managementIn 2012, WHO prioritised clinical risk management in primary care, forming its Safer Primary Care Expert Working Group that recently produced a technical series.69 70 International data suggest that safety incidents in primary care are mainly diagnostic and prescribing errors, with a rate estimated between <1 and up to 24 safety incidents per 100 consultations reviewed.71 Key elements influencing patient safety are related to struc-tural and technological prerequisites (eg, electronic health records, decision support systems), including organisational structure (eg, leadership, governance structure, organisation of work shifts, workload); human factors (eg, individual perception, diligence, decision-making ability, professionalism, interpersonal and group dynamics) and community characteristics (eg, epidemiological profile, resilience), and external influences (eg, media and public opinion). At the inter-national level, the commitment to improving safety in primary care has focused mainly on building and imple-menting incident-reporting systems, and on proactive or reactive risk analysis systems (eg, analysis of crit-ical incidents and adverse events, root cause analysis, failure mode effect analysis). Several interventions in primary care at the local level have been suggested by national agencies, including improving incident and adverse event reporting, integrating comprehensive risk management systems and continuous learning environments. Specifically, pharmacist-led medication review, computerised physician order entry, computer-ised decision support systems, error alert systems and education of professionals have all been shown to be effective interventions that could potentially prevent up to half of all errors.71
education and learningA continuous, proactive learning environment in primary care enables health professionals to deepen their knowl-edge and expand their skills, which even at the end of
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
15Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
formal postgraduate professional medical are insufficient to ensure competence and performance over a life-long career. In addition, continuing professional development systems whose relevance has been widely recognised,72. Ways to keep clinicians updated with practice relevant information have evolved since the late 1990s, in the form of useful criteria to identify patient-oriented, evidence-based information. One example is the Information Mastery framework, which emphasises Patient-Ori-ented Evidence that Matters (POEMs) of Slawson et al.46 POEMs are studies that are relevant to primary care deci-sion-making, have been assessed for validity and have the potential to change practice. Each year, only about 200–250 studies from the top 100 clinical journals meet these criteria. An evolution of this concept has been translated into an online resource, Essential Evidence Plus, which is unique in comparison to other point-of-care tools in that it provides daily emailed POEMs to subscribers.73
Regarding the telephone and email consultation skills of clinicians, which are important for effective remote consulting, we do not yet have strong evidence regarding how health professionals should be trained to make the best use of this communication challenge.52 Educa-tional gaming is potentially a way to improve health professionals’ knowledge and skills, in particular for its motivating competitive nature. However, evidence of its effectiveness is limited, with only two studies identified and no difference seen between the intervention and control groups.74
Interprofessional education is increasingly recom-mended as an approach that has the potential to improve communication between different types of healthcare providers, as well as an improved understanding of the skills and capabilities of different team members, and better team functioning. However, the evidence regarding its effectiveness is limited. In one study, improvements in diabetic health outcomes, greater attainment of health-care quality goals and improved patient satisfaction and team behaviour have been reported and sustained over time.75
This framework however has a number of limitations. First of all, the umbrella review considered only EPOC Group and Cochrane Library database, other systematic review or meta-analysis not included in this paper could be examined to support and develop evidence-based healthcare management. Another limitation is the diffi-cult to derive evidence easily transferable by researches in healthcare services. In fact, the generalisability or transferability of healthcare services research findings from one setting to another could be also often prob-lematic. Furthermore, the importance of local organisa-tional context and culture, and the structural differences in health organisations and health systems make chal-lenging the exportation of organisational models. However, the a culture that supports and encourages innovation in organisational models should stimulate managers in routinely reviewing the findings of relevant
research studies and research syntheses before making important decisions.76
COnClusIOnsThe number of patients with chronic diseases will continue to increase with the ageing of the population, and the ongoing existence of risk factors for chronic diseases. We offer this framework with the aim of shedding light on how to reorganise primary care health systems, identifying and implementing an organic approach to optimising care for patients with chronic disease. Implementing such a framework will be a responsibility shared by the public and private health sectors, as well as by the communities where patients live and the primary health system oper-ates. Strengthening partnerships with and between these sectors will be crucial to achieving the vision of a quality of care for multiple chronic conditions.
Author affiliations1Unit of Hygiene and Public Health, Department of Cardiologic, Vascular, Thoracic Sciences and Public Health, Laboratory of Health Care Services and Health Promotion Evaluation, University of Padova, Padova, Italy2Past Administrative Directorship, ex-ULSS 4, Veneto, Italy3Department of Cardiologic, Vascular, Thoracic Sciences and Public Health, School of Hygiene and Preventive Medicine, University of Padova, Padova, Italy4Department of Public Health, Università Cattolica Sacro Cuore - Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy5College of Public Health, University of Georgia, Athens, Greece, USA
Contributors AB, RT and VB: conceptualisation, design of the methodologies, wrote and approved the final manuscript as submitted. MC: review analysis, wrote and revised the manuscript, approved the final manuscript as submitted. GD: conceptualisation, supervision of the study, approved the final manuscript as submitted. MHE and WR: supervision, critically reviewed the manuscript, approved the final manuscript as submitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
data sharing statement No additional data available.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
reFerenCes 1. Starfield B. Primary care: an increasingly important contributor to
effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit 2012;26:20–6.
2. van den Akker M, Buntinx F, Metsemakers JF, et al. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 1998;51:367–75.
3. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002;162:2269–76.
4. Van Lerberghe W. The world health report 2008: primary health care: now more than ever. Geneva: World Health Organization, 2008.
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
16 Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
5. World Health Organization. Everybody’s business-strengthening health systems to improve health outcomes: WHO’s framework for action, 2007.
6. World Health Organization. ROADMAP. Strengthening people-centred health systems in the WHO European Region: a Framework for Action towards Coordinate, 2013.
7. Coulter A, Roberts S, Dixon A. Delivering better services for people with long-term conditions building the house of care: The King’s Fund 2013.
8. Thomas S. Improvement slow in care quality: Primary Health Care 2010.
9. Anonymous. The new NHS modern. dependable: The Department of Health, 1997.
10. Specchia ML, La Torre G, Siliquini R, et al. OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers. BMC Health Serv Res 2010;10:174.
11. Botje D, Plochg S, Klazinga N, et al. Clinical governance in Dutch hospitals. Clin Govern Int J 2014;19:322–31.
12. Meads G, Russell G, Lees A. Community governance in primary health care: towards an international ideal type. Int J Health Plann Manage 2017;32:554–74.
13. Flynn MA, Burgess T, Crowley P, et al. Supporting and activating clinical governance development in Ireland: sharing our learning. J Health Organ Manag 2015;29:455–81.
14. Sadeghi-Bazargani H, Tabrizi JS, Azami-Aghdash S. Barriers to evidence-based medicine: a systematic review. J Eval Clin Pract 2014;20:793–802.
15. Tait AR. Clinical governance in primary care: a literature review. J Clin Nurs 2004;13:723–30.
16. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511–44.
17. Scally G, Donaldson LJ. The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5.
18. Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med 2011;9:100–3.
19. Corrigan JM, Swift EK, Hurtado MP. Envisioning the national health care quality report: National Academies Press, 2001.
20. Institute of Medicine. Medicare: a strategy for quality assurance: National Academy Press, 1990.
21. Lohr KN. Concepts of assessing, assuring, and improving quality, 1990.
22. Donabedian A. Evaluating the Quality of Medical Care. Milbank Mem Fund Q 1966;44:166–206.
23. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71–2.
24. Moskowitz D, Bodenheimer T. Moving from evidence-based medicine to evidence-based health. J Gen Intern Med 2011;26:658–60.
25. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014:CD000011.
26. Oborn E, Barrett M, Racko G. Knowledge translation in healthcare: a review of the literature. Cambridge, UK, 2010.
27. Smith SM, Wallace E, O'Dowd T, et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016;9.
28. Celler B, Varnfield M, Nepal S, et al. Before and after control intervention analysis. JMIR Med Inform 2017;3:e29.
29. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633–8.
30. Parmelli E, Flodgren G, Fraser SG, et al. Interventions to increase clinical incident reporting in health care. Cochrane Database Syst Rev 2012:CD005609.
31. Cooper JA, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open 2015;5:e009235.
32. Dagger TS, Sweeney JC, Johnson LW. A hierarchical model of health service quality. J Serv Res 2007;10:123–42.
33. Ballini L, Negro A, Maltoni S, et al. Interventions to reduce waiting times for elective procedures. Cochrane Database Syst Rev 2015:CD005610.
34. Shepperd S, Gonçalves-Bradley DC, Straus SE, et al. Hospital at home: home-based end-of-life care. Cochrane Database Syst Rev 2016;S5.
35. Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns 2010;79:277–82.
36. Halligan A, Donaldson L. Implementing clinical governance: turning vision into reality. BMJ 2001;322:1413–7.
37. Légaré F, Stacey D, Turcotte S, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2014:CD006732.
38. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017;19.
39. Garrido MV. Health technology assessment and health policy-making in Europe: current status challenges and potential: WHO Regional Office Europe. 2008.
40. Kleinert S, Horton R. South Africa's health: departing for a better future? Lancet 2009;374:759–60.
41. Coffey A, Mulcahy H, Savage E, et al. Transitional care interventions: Relevance for nursing in the community. Public Health Nurs 2017;34:454–60.
42. Reeves S, Pelone F, Harrison R, et al. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017;6:CD000072.
43. Renders CM, Valk GD, Griffin SJ, et al. Interventions to improve the management of diabetes mellitus in primary care outpatient and community settings. The Cochrane Library 2000.
44. McClellan M, Kent J, Beales S, et al. Focusing accountability on the outcomes that matter: Report of the Accountable Care Working Group 2013. Brookings Institution Report. https://www. brookings. edu/ wp- content/ uploads/ 2016/ 06/ 27425_ WISH_ Accountable_ care_ Report_ AW- Web. pdf
45. Essel V, Van Vuuren U, De Sa A, et al. Auditing chronic disease care: Does it make a difference? Afr J Prim Health Care Fam Med 2015;7:1–7.
46. Slawson DC, Shaughnessy AF, Bennett JH. Becoming a medical information master: feeling good about not knowing everything. J Fam Pract 1994;38:505–14.
47. Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA 2010;304:1715–6.
48. Rogan L, Boaden R. Understanding performance management in primary care. Int J Health Care Qual Assur 2017;30:4–15.
49. Anonymous. Final report Conference "Which priorities for a European policy on Multimorbidity?", 2015.
50. Barr VJ, Robinson S, Marin-Link B, et al. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp Q 2003;7:73–82.
51. Dalkir K, Liebowitz J. Knowledge management in theory and practice: MIT press, 2011.
52. Pillay M, Dennis S, Harris MF. Quality of care measures in multimorbidity. Aust Fam Physician 2014;43:132.
53. Tarlov AR, Ware JE, Greenfield S, et al. The Medical Outcomes Study. an application of methods for monitoring the results of medical care. JAMA 1989;262:925–30.
54. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ 2017;356:j84.
55. Druss BG, Zhao L, Cummings JR, et al. Mental comorbidity and quality of diabetes care under Medicaid: a 50-state analysis. Med Care 2012;50:428.
56. Liu CW, Einstadter D, Cebul RD. Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care 2010;16:413–20.
57. Lemire M, Demers-Payette O, Jefferson-Falardeau J. Dissemination of performance information and continuous improvement: a narrative systematic review. J Health Organ Manag 2013;27:449–78.
58. Papp R, Borbas I, Dobos E, et al. Perceptions of quality in primary health care: perspectives of patients and professionals based on focus group discussions. BMC Fam Pract 2014;15:128.
59. Crow R, Gage H, Hampson S, et al. The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. Health Technol Assess 2002;6:352.
60. Remmers C, Hibbard J, Mosen DM, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage 2009;32:320–7.
61. Grady PA, Gough LL. Self-management: a comprehensive approach to management of chronic conditions. Am J Public Health 2014;104:e25–e31.
62. Ryan P, Sawin KJ. The individual and family self-management theory: background and perspectives on context, process, and outcomes. Nurs Outlook 2009;57:217–25.
63. Adair CE, Simpson L, Birdsell JM, et al. Performance measurement systems in health and mental health services: Models, practices and effectiveness, A State of the Science Review. Alberta Heritage Foundation for Medical Research 2003.
64. Bruett T, Barres I, Curran L, et al. Measuring performance of microfinance institutions. Washington: SEEP Network, 2005.
on January 16, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2017-020626 on 28 July 2018. Dow
nloaded from
17Buja A, et al. BMJ Open 2018;8:e020626. doi:10.1136/bmjopen-2017-020626
Open access
65. Anon. Multiple chronic conditions measurement framework. National Quality Forum 2012.
66. National Health Reform Agreement. Performance and Accountability Framework: National Health Performance Authority, 2011.
67. Farmer C, Fenu E, O'Flynn N, et al. Clinical assessment and management of multimorbidity: summary of NICE guidance. BMJ 2016;354:354.
68. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management (NICE clinical guideline 56), 2016.
69. Mercer S, Furler J, Moffat K, et al. Multimorbidity: technical series on safer primary care. 2016.
70. World Health Organization. Summary of the inaugural meeting the safer primary care expert working group. Geneva: World Health Organization, 2012:19.
71. Panesar SS, Carson-Stevens A, Cresswell KM, et al. How safe is primary care? A systematic review. BMJ quality & safety 2015:004178.
72. Horsley T, Grimshaw J, Campbell C. How to create conditions for adapting physicians’ skills to new needs and lifelong learning. Copenhagen: WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies, 2010.
73. Koos JA. Essential Evidence Plus. J Med Libr Assoc 2017;105:302. 74. Vaona A, Pappas Y, Grewal RS, et al. Training interventions for
improving telephone consultation skills in clinicians. Cochrane Database Syst Rev 2017;1:CD010034.
75. Akl EA, Kairouz VF, Sackett KM, et al. Educational games for health professionals. The Cochrane Library 2013.
76. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q 2001;79:429–57.
77. Arditi C, Rège-Walther M, Durieux P, et al. Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017;7:CD001175.
78. Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev 2014:CD005188.
79. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, et al. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2012;10:CD009009.
80. Archambault PM, van de Belt TH, Kuziemsky C, et al. Collaborative writing applications in healthcare: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017;5:CD011388.
81. Fiander M, McGowan J, Grad R, et al. Interventions to increase the use of electronic health information by healthcare practitioners to improve clinical practice and patient outcomes. Cochrane Database Syst Rev 2015:CD004749.
82. Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2015:CD002098.
83. Flodgren G, Hall AM, Goulding L, et al. Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database Syst Rev 2016:CD010669.
84. Chen CE, Chen CT, Hu J, et al. Walk-in clinics versus physician offices and emergency rooms for urgent care and chronic disease management. Cochrane Database Syst Rev 2017;2:CD011774.
85. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011:CD008451.
86. Young C, Hall AM, Gonçalves-Bradley DC, et al. Home or foster home care versus institutional long-term care for functionally dependent older people. Cochrane Database Syst Rev 2017;4:CD009844.
87. Nkansah N, Mostovetsky O, Yu C, et al. Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev 2010:CD000336.
88. Gonçalves-Bradley DC, Lannin NA, Clemson LM, et al. Discharge planning from hospital. Cochrane Database Syst Rev 2016:CD000313.
89. Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014:CD007768.
90. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2014:CD008165.
91. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012:CD000259.
92. Gillaizeau F, Chan E, Trinquart L, et al. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013:CD002894.
93. Alldred DP, Kennedy MC, Hughes C, et al. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev 2016;2:CD009095.
94. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012;12:CD003267.
95. Ciciriello S, Johnston RV, Osborne RH, et al. Multimedia educational interventions for consumers about prescribed and over-the-counter medications. Cochrane Database Syst Rev 2013:CD008416.
96. Atherton H, Sawmynaden P, Sheikh A, et al. Email for clinical communication between patients/caregivers and healthcare professionals. Cochrane Database Syst Rev 2012;11:CD007978.
97. Weeks G, George J, Maclure K, et al. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016;11:CD011227.
98. Flodgren G, Parmelli E, Doumit G, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2011:CD000125.
99. Green CJ, Maclure M, Fortin PM, et al. Pharmaceutical policies: effects of restrictions on reimbursement. Cochrane Database Syst Rev 2010;8:CD008654.
100. Jia L, Yuan B, Huang F, et al. Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database Syst Rev 2014:CD008194.
101. Smith SM, Cousins G, Clyne B, et al. Shared care across the interface between primary and specialty care in management of long term conditions. Cochrane Database Syst Rev 2017;2:CD004910.
102. Hayes SL, Mann MK, Morgan FM, et al. Collaboration between local health and local government agencies for health improvement. Cochrane Database Syst Rev 2012;10:CD007825. on January 16, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-020626 on 28 July 2018. D
ownloaded from