September, 2009 - SUPPORT Summary of a systematic review | print this article |

Does prompting physicians improve performance in preventive care?

Physicians prompts can be defined as different mechanisms designed to periodically remind them to perform some action(s) with their patients in order to achieve some defined objective(s) or clinical outcomes, such as the delivery of preventive interventions.

Key messages

 

  • All the studies were done in high income countries which constitute a limitation to the application of the findings to low and middle-income countries.
  • Prompting physicians probably can improve performance in preventive care. This includes different preventive procedures such as faecal blood occult test, mammogram, PAP smear, influenza, tetanus and pneumonia vaccination, among others.
  • Both computer and non-computer generated prompts may improve performance in preventive care.
  • There is a lack of cost-effectiveness studies comparing different ways of generating and/or delivering the prompts.
  • Access to preventive services is a requisite for the effectiveness of this kind of interventions. Therefore, coverage of preventive services should be considered when implementing them.

Who is this summary for?

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:

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

Health systems are encouraging organizations and individual physicians to use every episode of patient care to promote health maintenance. Physician prompts –defined as the different mechanisms destined to periodically remind the clinician to perform some action(s) with their patients– have been used with this aim. They are delivered before a scheduled encounter, can be presented in different formats, be computer or noncomputer generated and can contain a variety of information for the physicians, such as patient name and/or diagnosis, notice of deviation from standard, criteria for procedures or tests and recommendation for treatment, indication of upcoming or previous procedures or tests, space for clinician to indicate that the procedure or test was offered or why it was not offered. There is no specification in the review about what actions are involved in the non-computer generated prompts.

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

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 included 33 studies, with data on 1,547 physicians and 54,693 patients. All the studies were RCTs and were done in high-income settings (mostly the USA). It included preventive procedures related to cancer screening (faecal occult blood, mammography, Papanicolaou smear); immunization (influenza, pneumococcal, tetanus); diabetes, cholesterol, hemoglobin and blood pressure management and follow-up; cardiac care, smoking cessation, glaucoma screening, alcohol abuse counseling, prenatal care, and tuberculosis testing.

1) Prompts compared with no prompts to physicians

The 33 studies identified reported this comparison. In 13 studies (27,889 patients; 51% of the total) patients were reminded in addition to physicians.

  • Prompting physicians probably improves the performance of preventive care actions by patients.
  • There was not enough data to estimate the total costs of the intervention.

 

2) Computer-generated prompts compared with no prompts

25 studies assessed this comparison. In 11 studies (27,387 patients; 54,7% of the total) patients were reminded in addition to physicians.

  • Computer-generated prompts probably improve the performance in preventive care.

 

 

3) Non-computer generated prompts compared with no prompts

8 studies assessed this comparison. In 2 studies (659 patients; 14,2% of the total) patients were reminded in addition to physicians.

  • Non-computer generated prompts may improve the performance of preventive care

Relevance of the review for low-income countries

Additional information

Related literature

An overview summarising the findings of systematic reviews of the effectiveness of different interventions to improve professional practice: 

Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman AD, O'Brien M. 

Changing provider behavior: An overview of systematic reviews of interventions. Medical Care 2001; 39: Supplement 2, II-2 - II-45.

A systematic review assessing the effectiveness of various guideline dissemination and implementation strategies across different types of professional practice, including the delivery of preventive services:Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8: (6). http://www.hta.nhs.uk/fullmono/mon806.pdf

 

Systematic reviews evaluating the effectiveness of different strategies to change professional practice: Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004398.

 

Jacobson Vann JC, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003941.

 

Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000259.

 

A tool that provides a range of information, checklists, examples and tools based on current research on how to best design and evaluate quality improvement interventions: NorthStar - how to design and evaluate quality improvement interventions in healthcare. http://www.rebeqi.org/?pageID=36&ItemID=18

 

This summary was prepared by

Cristian Herrera and Tomás Pantoja, School of Medicine, Pontificia Universidad Católica de Chile

 

Conflict of interest

None declared. For details, see: http://www.support-collaboration.org/summaries/coi.htm

 

Acknowledgements

This summary has been peer reviewed by: Martin Eccles, UK; Mike English, Kenya; George Pariyo, Uganda; Esperança Sevene , Alda do Rosário Elias Mariano and Julie Cliff, Mozambique.

 

This summary should be cited as

Herrera C, Pantoja T. Does prompting physicians improve performance in preventive care? A SUPPORT Summary of a systematic review. September 2009. http://www.supportcollaboration.org/summaries.htm



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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