August, 2016 - SUPPORT Summary of a systematic review | print this article |

Does practice facilitation in primary care settings improve adoption of evidence-based guidelines?

Practice facilitation is a multifaceted approach whereby skilled individuals, either internal or external to a setting, are used to promote adoption and use of evidence-based guidelines within the setting (practice).

 

Key messages

  •  The use of practice facilitation as a multifaceted approach probably improves the adoption of evidence-based guidelines in primary care setting.
  • All studies of the effects of practice facilitation were con-ducted in high-income countries.
    •  Further research is needed to determine the effectiveness and cost implications of practice facilitation in low-income countries.

 

Who is this summary for?

People making decisions on strategies to improve adoption of evidence-based guidelines

 

 

This summary includes:

  • Key findings from research based on a systematic review
  • Considerations about the relevance of this research for low income countries

Not included:

  • Recommendations
  • Additional evidence not included in the systematic review
  • Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74.

 

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Adoption of evidence-based guidelines is a challenge in many primary care settings because availability of knowledge alone is often insufficient to change practice. Lecture-based educative strategies to disseminate evidence-based guidelines are often ineffective, while multifaceted interventions such as interactive education and reminders may be more effective. Practice facilitation is a multifaceted approach that uses internal or external individuals to encourage evidence-based practice.

 

 

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.



About the systematic review underlying this summary

Review objectives: To undertake a quantitative synthesis of the effect of practice facilitation on evidence-based practice behaviour
 
Type ofWhat the review authors searched forWhat the review authors found

Study designs & interventions

Randomized and non-randomized trials and prospective studies of individual practice facilitation

 

23 studies of practice facilitation interventions (17 randomized trials, three cluster randomized trials, and three non-randomized studies)

 

Participants

All healthcare providers in primary care practices

 

Studies included 1,398 practices (697 allocated to facilitation intervention and 701 in the control group)

 

Settings

Primary care settings

 

Primary care practices in the USA (12 studies), the Netherlands (5), Canada (3), the UK (2) and Australia (1)

 

Outcomes

Change in evidence-based practice behaviour

 

Studies reported this outcome in varied ways, such as increased screening or management of different conditions and improvements in care provided

 

Date of most recent search: December 2010

 

Limitations: This is a well-conducted systematic review. However, the literature searches were restricted to English-language studies.

 
Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74

Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74.

 

About the certainty of the 
evidence (GRADE)


High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.


Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.


Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.


Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The review found 23 studies conducted in high-income countries that evaluated the use of practice facilitation to improve adoption of evidence-based guidelines. About half of the studies in the review used registered nurses or masters’ educated individuals with training as practice facilitators. Most of the studies focused primarily on preventive care.

A key component in all the studies was audit with feedback. Most studies also included interactive consensus building and goal setting, and many incorporated collaborative meetings, either face to face or virtual. The intensity of the interventions varied (from two meetings each 0.25 hrs to 18 meetings each six hours), as did the duration (two to 26 months).

Increased intensity, fewer practices per facilitator, and whether the intervention was tailored to fit the needs of the pratice, were all associated with stronger effects.

Practice facilitation for improving adoption of evidence-based guidelines in primary care settings

23 studies conducted in primary care settings in high-income countries measured the mean change in target behavior as a result of the intervention. 

  • Practice facilitation probably improves the adoption of evidence-based guidelines in primary care settings. The certainty of this evidence is moderate.

 

 Practice facilitation for adoption of evidence-based guidelines

Patient or population: Healthcare providers in primary care practices

Settings: High-income countries

Intervention: Practice facilitation

Comparison: No practice facilitation

Outcomes

 

Absolute effect


 Relative effect
(95% CI)		 Certainty of the evidence
(GRADE)
Without
practice facilitation
 With
practice facilitation
   

Desired professional

practice (adherence to guideline

recommendations)

Moderate adherence* 60 per 100

 

  81 per 100

 

OR 2.76 (2.18 to 3.43)

   

Difference: 21 more patients receiving recommended practice per 100 patient enconunters (Margin of error: 17 to 24 more)

 

    
 

Low adherence*

 

 

    
  20 per 100 41 per 100    
   

Difference: 21 more patients receiving recommended practice per 100 patient encounters (Margin of error: 15 to 26 more)

 

    
 

Margin of error = Confidence interval (95% CI)    OR:  Odds ratio     GRADE: GRADE Working Group grades of evidence (see above and last page)

* For the SUPPORT-summary we selected two levels of baseline adherence to desired practice to help interpret the overall odds ratio (and its 95% confidence interval). Moderate adherence was assumed at 60% of desired practice while low adherence was assumed at 20% of desired practice.

† The OR and confidence intervals are from a meta-analysis using standardized mean differences (SMD), converted to an odds ratio by the review authors (SMD=0.56, 95% CI 0.43 to 0.68).

‡ The certainty of the evidence is moderate because of study limitations (risk of bias) in some of the included studies and heterogeneity of results.

 

 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

 

  •  The review did not include any studies conducted in low-income countries that evaluated the use of practice facilitation to promote adoption of evidence-based guidelines.

 

 
  • Practice facilitation might be difficult to implement in low-resource settings, particularly the audit and feedback component, and it might be more difficult to make necessary organisational changes such as implementation of quality improvement tools.
EQUITY
  •  The studies identified by the review did not address the issue of equity.

 

  •  Poor adherence to evidence-based guidelines often impacts more on disadvantaged populations. Practice facilitation as a strategy to improve evidence-based guideline adoption could help these populations achieve the benefits of better quality service. However, practice facilitation might be more difficult to implement in disadvantaged settings.

 

 
ECONOMIC CONSIDERATIONS

 

  •  The studies included in the review did not provide any data on the costs of practice facilitation as an intervention.

 

 

 

  •  It is not possible to estimate the cost-effectiveness of practice facilitation based on the available information.

 

 
MONITORING & EVALUATION

 

  •  The review did not find any evidence of the effect of practice facilitation in low-income countries and did not report any findings of the cost-effectiveness. 

 

 

  •  If practice facilitation is used in low-income countries, its effects and cost-effectiveness should be evaluated, preferrably in (cluster) randomised trials.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 


Additional information

Related literature

Nagykaldi Z, Mold JW, Aspy CB. Practice facilitators: a review of the literature. Fam Med. 2005;37(8):581-588.

 

Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/index.html

 

O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and

health care outcomes. Cochrane Database of Systematic Reviews 2007, Issue 4.

 

This summary was prepared by

Michael Gathu, KEMRI-Wellcome Trust Research Programme, Kenya

 

Conflict of interest

None Declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Mike English, Mary Ann O'brien, Bruce Baskerville, and Atle Fretheim

 

This review should be cited as

Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012; 10:63-74.

 

The summary should be cited as

Gathu M. Does practice facilitation in primary care settings improve adoption of evidence-based guidelines? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

 

Keywords

All Summaries:

evidence-informed health policy, evidence-based, systematic review, health systems research,

health care, low and middle-income countries, developing countries, primary health care

practice facilitation, quality improvement, primary care, audit, feedback, guideline adoption,

guideline adherence

 



About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

To receive e-mail notices of new SUPPORT summaries or provide feedback on this summary, go to: www.supportsummaries.org/contact

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