SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
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
-Further research is needed to determine the effectiveness and cost implications of practice facilitation in low-income countries.
People making decisions on strategies to improve adoption of evidence-based guidelines
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.
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.
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.
|
Review objectives: To undertake a quantitative synthesis of the effect of practice facilitation on evidence-based practice behaviour |
||
| Type of | What the review authors searched for | What 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 |
All healthcare providers in primary care practices |
|
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.
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.
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 for adoption of evidence-based guidelines |
|||||
| People: 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 |
||||
| Difference (Margin of error) |
|||||
|
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 encounters (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. |
|||||
| 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. |
|
| EQUITY | |
|
The studies identified by the review did not address the issue of equity. |
|
| ECONOMIC CONSIDERATIONS | |
|
The studies included in the review did not provide any data on the costs of practice facilitation as an intervention. |
|
| 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. |
|
|
*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 |
|
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.
