Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

 

Abstract

Background

In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.

Objectives

To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.

Search methods

For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007.  We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.

Selection criteria

Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.

Data collection and analysis

Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.

1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.

2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.

Main results

We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.

Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.

Authors' conclusions

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.

 

Plain language summary

Tailored interventions to overcome identified barriers to change effects on professional practice and health care outcomes

Tailored interventions to change professional practice are interventions planned following an investigation into the factors that explain current professional practice and any reasons for resisting new practice. These factors are referred to as barriers to change. The barriers may vary in different healthcare settings, groups of healthcare professionals or clinical tasks. It is widely assumed that efforts to change professional practice have a lower likelihood of success unless these barriers are identified and taken into account.

In a previous review that was able to include only 15 studies, we were unable to conclude that tailoring was effective. However, more studies of tailoring have been published and therefore we have incorporated the new studies into an update of the review.

We have included 26 studies in the new review. The findings indicate that tailored interventions can change professional practice. As yet, there is insufficient evidence on the most effective approaches to tailoring, including how barriers should be identified and how interventions should be selected to address the barriers. In addition, there is no evidence about the cost-effectiveness of tailored interventions compared to other interventions to change professional practice. Consequently, it is reasonable to employ low-cost tailored interventions in practice, but evidence on the cost-effectiveness of the alternative methods of tailoring is required before use of more costly tailored approaches can be justified.

 

摘要

背景

克服已確認的改變障礙之適當介入措施︰對專業實務和健康照護結果的影響

在先前評論的版本，對改變障礙的介入措施的有效性，發現是不確定的。

目標

在專業績效中，針對特定、已被辨識的改變障礙，評估執行適當策略的效果。

搜尋策略

此篇更新，除了EPOC登記及未完成的檔案，我們搜尋以下資料庫，沒有語言限制、從開始直到2007年8月。MEDLINE, EMBASE, CINAHL, BNI 及 HMIC。我們搜尋全國性的有登記的研究到2007年11月。我們更進一步的繼續進行搜尋到2009年10月的研究，以辨別潛在的符合出版或進行中的試驗。

選擇標準

報告客觀的測量專業實務或健康照護結果的隨機對照試驗(RCTs)，其至少有一個團體，針對前瞻性的已被確認的改變障礙，接受針對障礙所設計的適當介入措施(或合適的)。

資料收集與分析

兩位評論者獨立的摘取資料及評估品質。我們也接觸研究作者以獲得任何缺失的資料。進行量化和質性的分析

主要結論

我們納入26篇研究針對已被確認的改變障礙，比較一種適當的介入措施對沒有措施或一種不適當的措施。結果在研究之間及之內的效果大小不一致。12篇研究提供足夠的資料作量性的分析。一個統合回歸模式，獲得來自貝氏分析的pooled odds ratio 1.54 (95% CI, 1.16 to 2.01)，及來自傳統分析的1.52 (95% CI, 1.27 to 1.82, P < 0.001) 。異質性分析發現所調查的研究屬性沒有顯著的和介入措施的有效性相關。

作者結論

Baker Richard, CamossoStefinovic Janette, Gillies Clare, Shaw Elizabeth J, Cheater Francine, Flottorp Signe, Robertson Noelle 適當的介入措施可以改變專業實務。可是，沒有足夠的證據顯示最有效的適當的方法，包括障礙該如何確認及對於障礙應該選擇何種措施。

翻譯人

本摘要由高雄榮民總醫院林麗英翻譯。

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

總結

適當的介入措施對克服已確認的改變障礙在專業實務及健康照護結果的效果。 適當的介入措施去改變專業實務是有計畫的措施，跟隨著一個因素調查之後，它解釋目前的專業實務及任何阻礙新實務的理由。這些因素是改變的障礙。這些障礙在不同的專業環境、健康專業團體或臨床作業可能是不同的。它被廣泛的假設，努力的去改變專業的實務有較低的成功可能性，除非是辨別及考慮到這些障礙。在先前的評論，僅包括15篇研究，我們無法結論適當措施的效果。無論如何，更多適當介入措施的研究被刊登及因此我們合併這些新的研究進入更新評論。在新的評論中我們包括了26篇研究。這些發現顯示適當的介入措施可以改變專業實務。可是，沒有足夠的證據顯示最有效的適當的方法，包括障礙該如何確認及對於障礙應該選擇何種措施。另外，沒有證據關於改變專業實務的適當措施比較於其他措施的成本效益。因此在實務中它是有理由去使用較低成本的適當措施，但是在使用更多高價適當措施之前，替代方案成本效益的證據是需要的，以作為使用方案的正當理由。