Printed educational materials: effects on professional practice and health care outcomes

 

Abstract

Background

Printed educational materials (PEMs) are widely used passive dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines and appear to be the most frequently adopted method for disseminating information.

Objectives

To determine the effectiveness of PEMs in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes

To explore whether the effect of characteristics of PEMs (e.g., source, content, format, mode of delivery, timing/frequency, complexity of targeted behaviour change) can influence process outcomes (including the behaviour of healthcare professionals and patient outcomes).

Search methods

The following electronic databases were searched up to July 2006: (a) The EPOC Group Specialised Register (including the database of studies awaiting assessment (see 'Specialised Register'under 'Group Details'); (b) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness; (c) MEDLINE, EMBASE, CINAHL and CAB Health. An updated search of MEDLINE was done in March 2007.

Selection criteria

We included randomised controlled trials (RCTs) , controlled clinical trials (CCT), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) that evaluated the impact of printed educational materials on healthcare professionals' practice and/or patient outcomes. There was no language restriction. Any objective measure of professional performance (sch as number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g., blood pressure, number of caesarean sections) were included.

Data collection and analysis

Four reviewers undertook data abstraction independently using a modified version of the EPOC data collection checklist. Any disagreement was resolved by discussion among the reviewers and arbitrators. Statistical analysis was based upon consideration of dichotomous process outcomes, continuous process outcomes, patient outcome dichotomous measures and patient outcome continuous measures. We presented the results for all comparisons using a standard method of presentation where possible. We reported separately for each study the median effect size for each type of outcome, and the median of these effect sizes across studies.

Main results

Twenty-three studies were included for this review. Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice. RCTs comparing PEMs to no intervention observed an absolute risk difference median: +4.3% on categorical process outcomes (e.g., x-ray requests, prescribing and smoking cessation activities) (range -8.0% to +9.6%, 6 studies), and a relative risk difference +13.6% on continuous process outcomes (e.g., medication change, x-rays requests per practice) (range -5.0% to +26.6%, 4 studies). These findings are similar to those reported for the ITS studies, although significantly larger effect sizes were observed (relative risk difference range from 0.07% to 31%). In contrast, the median effect size was -4.3% for patient outcome categorical measures (e.g., screening, return to work, quit smoking) (range -0.4% to -4.6%, 3 studies)). Two studies reported deteriorations in continuous patient outcome data (e.g., depression score, smoking cessation attempts) of -10.0% and -20.5%. One study comparing PEMs with educational workshops observed minimal differences. Two studies comparing PEMs and education outreach did not have statistically significant differences between the groups. It was not possible to explore potential effect modifiers across studies.

Authors' conclusions

The results of this review suggest that when compared to no intervention, PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes. Despite this wide of range of effects reported for PEMs, clinical significance of the observed effect sizes is not known. There is insufficient information about how to optimise educational materials. The effectiveness of educational materials compared to other interventions is uncertain.

 

Plain language summary

Printed educational materials: effects on professional practice and health care outcomes

Research results published in health care journals and printed clinical practice guidelines are commonly disseminated to health care providers.  These printed educational materials can be distributed to large numbers of health care professionals and are relatively cheap.  The goal of printing and disseminating educational materials is to improve awareness, knowledge, attitudes, skills, and professional practice of health care providers (process outcomes), and also to improve patient health outcomes.  This review suggests that when compared to no intervention, printed educational materials slightly improve process outcomes but not patient outcomes. When compared to other interventions, printed educational materials may slightly improve outcomes, but there is not enough evidence to be certain. It is not known under what circumstances and contexts printed educational materials are more effective or what specific characteristics of printed educational materials make them more effective.

 

摘要

背景

紙本教材：對於專家處置及健康照護結果的影響

紙本教材(Printed educational materials (PEMs))為廣泛使用的被動式傳播策略，以改善知識，認知，態度，技巧，專家處置及病患結果。傳統上以紙本的形式呈現，如專刊，發表於同儕審查的期刊及臨床指引，且其似乎是最常用來傳播資訊的方法。

目標

確定紙本教材對於改善過程面結果(包括健康照護專家的行為)及病患結果之效果。探究紙本教材的特性(如來源，內容，形式，發行的模式，時間／頻率，目標行為改變的複雜度)是否可以影響過程面結果(包括健康照護專家的行為及病患結果)。

搜尋策略

檢索下列的電子資料庫至2006年7月：(a)The EPOC Group Specialised Register(包括研究等候審查的資料庫)(參照‘Specialised Register’之‘Group Details’)；(b)The Cochrane Central Register of Controlled Trials (CENTRAL)及the Database of Abstracts of Reviews of Effectiveness；(c)MEDLINE，EMBASE，CINAHL及CAB Health。2007年5月完成更新MEDLINE的檢索。

選擇標準

我們蒐集隨機對照試驗(randomised controlled trials (RCTs))，對照臨床試驗(controlled clinical trials (CCT))，前後對照研究(controlled before and after studies (CBAs))及間斷時間序列分析(interrupted time series analyses (ITS))，有關評估紙本教材對於健康照護專家的處置及／或病患結果的影響。檢索策略不限制語言。蒐集任何有關專家行為的客觀測量(如檢驗的醫囑量,特定藥物的處方量)，或病人健康結果(如血壓，剖腹產人數)。

資料收集與分析

四名審查者分別使用修正版的EPOC資料蒐集清單來摘錄資料。所有的爭議經由審查者及公正人討論後獲得解決。依據測量類別與連續變項的過程面結果，及測量類別或連續變項的病患結果進行統計分析。我們盡可能以標準化的方法呈現所有的比較結果。我們分別報告每篇研究中各種結果其效應值(effect size)的中位數，及各個研究之間其效應值的中位數。

主要結論

這篇回顧蒐集了23篇研究。這篇回顧的證據顯示，紙本教材似乎對於專家處置有些微有利的影響。比較紙本教材相對於沒有介入措施之隨機對照試驗發現，類別的過程面結果(如要求xray，處方及戒菸活動)其絕對風險差的中位數(absolute risk difference median)為+4.3%(範圍從−8.0%至+9.6%，共6篇研究)，而連續的過程面結果(如藥物改變，每次處置要求xrays)其相對風險差為+13.6%(範圍從−5.0%至+26.6%，共4篇研究)。這些結果與間斷時間序列分析研究之報告相似，雖然有明顯較大的效應值(相對風險差範圍為0.07%至31%)。相反地，病患結果其類別變項測量(如篩檢，重返工作，戒菸)之效應值中位數為−4.3%(範圍為−0.4%至−4.6%，共3篇研究)。兩篇研究結果指出連續性的病患結果有惡化的情形(如憂鬱指數，戒菸意圖)，−10.0%及−20.5%。一篇研究比較紙本教材與教育工作坊發現有些微的差異。兩篇研究比較紙本教材與教育推廣，兩組間沒有統計學上顯著的差異.無法透過這些研究了解可能影響的修飾因素(modifiers)。

作者結論

這篇回顧的結果認為，相較於無介入措施，單獨使用紙本教材也許對過程面結果具有效益，但對於病患結果則沒有。儘管研究指出紙本教材有廣泛的效果，所觀察到的效應值其臨床重要性則是未知的。沒有充分的資訊有關如何使教材更為完善。教材相較於其他介入措施的效果並不明確。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

紙本教材：對於專家處置及健康照護結果的影響：發表在健康照護期刊的研究結果及紙本的臨床指引通常會發給健康照護提供者。這些紙本教材可以傳播給大量的健康照護專家且相對地便宜。印製並傳播教材的目的為改善健康照護提供者的認知，知識，態度，技巧及專家的處置，且同時改善病患的健康結果。這篇回顧認為相較於無介入措施，紙本教材也許可以有些微改善的結果，但沒有足夠的證據能夠確定。在何種情況及背景下紙本教材較有效,或何種紙本教材的特性可以使它們更為有效是未知的。