Background
Methods
Search
Inclusion criteria
Study design
Population
Intervention
Comparison group
Primary outcomes
Study selection and data extraction
Data analysis
Results
Results of the search
Included studies (Table 1)
Risk of bias in included studies
Effects of interventions
Education intervention
Audit and feedback
Academic detailing
Other interventions
Sensitivity and subgroup analyses
GRADE summary of findings tables
Study ID | Topic of trial | Study Design | Population description | Setting | Intervention Description; Intervention 2 description (if applicable) | Type | Duration of treatment period | Comparison intervention | Outcomes measured | Risk of bias ratinga |
---|---|---|---|---|---|---|---|---|---|---|
Ansari, 2003 | Use of beta-blockers in congestive heart failure | cRCT | Specialist doctors and nurse practitioners, patients with CHF | USA, urban medical centre | Nurse facilitator plus healthcare provider educational sessions; provider and patient reminder letters | Other type: Nurse facilitator; notifications | 1 year | Educational sessions, no nurse facilitator | Mortality, hospitalization, adherence (prescription review, chart review) | High risk of bias |
Baker, 2003 | Guidelines in prioritised review criteria | cRCT | Family doctors, patients with angina | England, general practices | Review criteria; criteria plus feedback | Other type: review criteria | 12 months | Guideline dissemination alone | Disease target (cholesterol), adherence (prescription review, chart review) | Low risk of bias |
Bertoni, 2009 | Physician adherence to ATP III guidelines | cRCT | Family doctors | USA, primary care practices | CDSS, educational sessions, academic detailing, CME sessions | Education + audit and feedback + academic detailing + CME session | 2 years | educational sessions, CME sessions, guideline mailed to participants | Disease target (cholesterol), adherence (prescription review, chart review) | High risk of bias |
Berwanger, 2012 | Multifaceted quality improvement intervention in ACS patients | cRCT | Patients with ACS at general public hospitals | Brazil, public hospitals | Training, reminders, checklists, case management, educational sessions | Education | 8 months | Routine care | Mortality, major adverse cardiac events, adherence (prescription review) | Low risk of bias |
Bonds, 2009 | Compliance to JNC 7 guidelines to improve blood pressure | cRCT | Family doctors | USA, primary care practices | Educational sessions, dissemination of guidelines, academic detailing for physicians, feedback on blood pressure control | Education + audit and feedback + academic detailing + CME sessions | 2 years | Similar to intervention but focused on ATPIII guidelines | Disease target (BP), adherence (prescription review, chart review) | Low risk of bias |
Browner, 1994 | CME and follow up to improve detection and treatment of high cholesterol | cRCT | Family and internal medicine doctors | USA, general practices | CME seminar; Intensive CME (office visits and educational materials) | Education + CME sessions | 18 months | Educational sessions | Disease target (cholesterol), adherence (chart review) | High risk of bias |
Carter, 2009 | Physician and pharmacist collaborative model to improve blood pressure | cRCT | Family doctors, patients with hypertension | USA, community based family medicine | Collaborative model, team building exercises, training sessions, educational sessions | Education + other (collaborative model) | 6 months | Collaborative model | Disease target (BP), guideline adherence tool | High risk of bias |
De Lusignan, 2013 | Audit based education to reduce blood pressure | cRCT | Mixed health care professionals | United Kingdom, primary care | Audit based education consisting of workshops; academic detailing plus workshops | Education + audit and feedback; academic detailing | 2 years | Usual care | Mortality, major adverse cardiac events, disease target (BP), adherence (prescription review) | Low risk of bias |
Deales, 2014 | Team based approach to disease and care management | cRCT | Mixed health care professionals | Italy, primary care groups | Recommendations as textbooks and decision algorithms, education sessions | Education | 12 months | Usual care | Disease target (HbA1c), adherence (chart review) | High risk of bias |
Dijkstra, 2006 | Implementation strategies for diabetes guidelines | cRCT | T1D and T2D patients | The Netherlands, hospitals | Educational meetings, feedback, reminder card; diabetes passport, education | Education + audit and feedback | 1 year | Usual care | Disease target (HbA1c), adherence (chart review) | High risk of bias |
Eaton, 2011 | Multimodal intervention to improve screening and management of hyperlipidemic patients | cRCT | Family doctors | USA, primary care practices | PDA with decision support and education toolkit and academic detailing | Academic detailing | 12 months | PDA with decision support but minimal follow up | Disease target (cholesterol), adherence (chart review) | Low risk of bias |
Eccles, 2002 | Computerised decision support system to implement angina guidelines | cRCT | Family doctors | England, general practices | Computer decision support that provided access to guidelines | Other: CDSS | 12 months | Same intervention but asthma guideline provided | Quality of life, adherence (chart review) | Low risk of bias |
Feldman, 2009 | Simplified algorithm for treatment of hypertension | cRCT | Family practices, patients with hypertension | Canada, family practices | Algorithm, aids, one follow up meeting, educational materials and sessions | Education + Other (algorithms) | 6 months | Educational sessions and guidelines | Mortality, disease target (BP), adherence (chart review) | Low risk of bias |
Fihn, 2011 | Collaborative care model based intervention to improve angina management | cRCT | Family doctors, patients with angina | USA, academic primary care clinics | Expert advice, progress evaluations, education | Education | 12 months | Usual care | Mortality, disease target, adherence (chart review) | Low risk of bias |
Fretheim, 2006 | Tailored intervention to support implementation of CVD guidelines | cRCT | Family practices, hypertensive or hypercholesterolemic patients | Norway, general practices | Tailored intervention including reminders, audit and feedback and education | Education + audit and feedback | 12 months | Passive dissemination | Disease target (cholesterol, BP), adherence (prescription review, chart review) | Low risk of bias |
Gill, 2009 | EMR-based intervention for lipid management | cRCT | Family doctors, general internists | USA, academic family practice | EMR disease management tool | Other (integration into EMR) | 12 months | Usual care | Disease target (cholesterol), adherence (chart review) | High risk of bias |
Goldstein, 2005 | Intervention on drug choice for hypertension | cRCT | Family doctors, nurse practitioners | USA, multiple sites | Education, individual drug profiles, follow up | Education | 9 months | Education on guidelines | Disease target (BP), adherence (prescription and chart review) | Low risk of bias |
Harris, 2005 | Teleconferenced educational detailing for diabetes | cRCT | Family doctors | Canada, family practices | Eight one hour small group educational sessions with opinion leaders | Education | 3 months | CME session after intervention period | Disease target (HbA1c), adherence (chart review) | High risk of bias |
Hayes, 2002 | Quality improvement and written feedback for CHF management | cRCT | Hospitals, CHF patients | USA, hospitals | Education, quality improvement tools from liaisons, chart reminders | Education + audit and feedback | 6 months | Mailed quality improvement tools | Disease target (ventricular fxn), adherence (chart review) | High risk of bias |
Headrick, 1992 | Education and feedback strategies to improve compliance with NCEP-PCEP guidelines | RCT | Resident doctors | USA. Academic hospital | Lecture, chart reminders; Lecture, patient specific feedback and chart reminder | Education + Other (reminders) | 20 weeks | Lecture alone | Disease targets (cholesterol), adherence (chart review) | Low risk of bias |
Hendriks, 2012 | Nurse led guideline based software supported ICCP | RCT | Family doctors, specialists, patients with atrial fibrillation | Netherlands, academic center | Nurse specialist educated patients and CDSS | Other (nurse specialist) | 12 months | Usual care | Mortality, hospitalizations, quality of life, adherence (chart review) | Low risk of bias |
Kiessling, 2011 | Case based training to optimize hyperlipidemia care | RCT | Family doctors, patients with CHD | Sweden, primary health care centres | Case based training seminars and guideline provided | Education | 2 years | Usual care | Mortality, disease target (cholesterol), adherence (prescription review) | High risk of bias |
Leonardis, 2012 | Multimodal intervention to improve adherence to targets | cRCT | Specialists, CKD patients | Italy, renal clinics | Education session, follow up and audits | Education + audit and feedback | 3 years | Education and standard care | Mortality, hospitalizations, quality of life, disease target (cholesterol), adherence (prescription/ chart review) | Low risk of bias |
Levine, 2011 | Multicomponent internet delivered intervention improve CHD guideline adherence | cRCT | Family doctors, MI patients | Virgin Islands and Puerto Rico, community primary care clinics | Educational cases, guidelines, monthly update, reminders | Education + Other (reminders) | 27 months | Passive dissemination | Disease target (cholesterol), adherence (chart review) | High risk of bias |
Ornstein, 2004 | Multimethod quality improvement intervention for adherence to quality indicators in CVD and stroke | cRCT | Practice based research network of practices | USA, primary care practices | Education, performance reports quarterly, practice site visits and network meetings (6–7 1–2 day visits) with pharmacist (academic detailing) | Education + academic detailing | 2 years | Education, performance reports quarterly | Disease target (BP), adherence (prescription, chart review) | High risk of bias |
Petersen, 2013 | Effect of financial incentives to reward guideline based hypertension care | cRCT | Family doctors | USA, primary care clinics | Physician level incentives; practice levels incetives; combined (both) incentives | Other (incentives) | 20 months | Usual care | Disease target (BP), adherence (prescription, chart review) | High risk of bias |
Peters-Klimm, 2009 | Educational model for GPs for the management of CHF | cRCT | Family doctors, CHF patients | Germany, general practitioner clinics | “Train the trainer” = multidisciplinary andragogic and didactic educational sessions | Education + Other (feedback) | 7 months | Single educational session by cardiologist | Mortality, hospitalizations, quality of life, disease target (course), adherence (prescription review) | Low risk of bias |
Reutens, 2012 | Education of GPs on the IDF-WPR guidelines to improve metabolic control | cRCT | Family doctors, T2D patients | Asia-Pacfic, general practitioner clinics | Education meetings (two 3 months apart), reminder letters and cards, flowsheet on patient notes, patient diabetes passport | Education + Other (reminders, diabetes passport) | 12 months | Instructed on assessments in study but no information on guidelines | Disease target (BP), adherence (chart review) | High risk of bias |
Rood, 2005 | Computer based guidelines to improve nurse measurement of patient glucose | RCT | ICU patients | The Netherlands, teaching hospital | Guideline based advice via computer decision support software | Other (decision support tool) | 10 weeks | Paper based guideline flowchart | Disease target (glucose), adherence (chart review) | High risk of bias |
Rossi, 1997 | Guideline reminders to improve prescribing based on JNC V guideline | cRCT | Nurse practitioners, hypertension patients | USA, GIM clinic | Guideline reminder for prescription and alternatives | Other (reminder) | 5 months | Usual care | Disease target (BP), adherence (prescription review) | High risk of bias |
Roumie, 2006 | Multifactorial intervention to improve quality of care of hypertension patients | cRCT | Physicians and nurse practitioners, hypertension patients | USA, community and hospital clinics | Alert on medical record; Educational sessions and alert on medical record | Education + other (alerts) | 6 months | Providers received email with guideline | Mortality, hospitalizations, disease target (BP), adherence (prescription review) | High risk of bias |
Simon, 2005 | Academic detailing individually or group to increase diuretic use in hypertension patients | cRCT | Family doctors, hypertension patients | USA, community health plan | Academic detailing meeting one-on-one; small group academic detailing session | Academic detailing | 3 months | Passive dissemination | Hospitalizations, disease target(BP), adherence (chart review) | High risk of bias |
Steyn, 2013 | Structured clinical record and training health care providers to control diabetes and hypertension | cRCT | Nurses, patients with diabetes and hypertension | South Africa, community health centres | Structured record with guideline embedded added to patient folders, educational package | Education | 1 year | Passive dissemination | Disease target (HbA1c), adherence (chart review) | High risk of bias |
Svetkey, 2009 | Intervention to increase physician adherence to BP guideline | cRCT | Physicians, hypertension patients | USA, community practice | CME courses, treatment algorithm, quarterly feedback on adherence | Education + CME session + other (feedback) | 18 months | Usual care | Disease target (BP), adherence (chart review) | Low risk of bias |
Tierney, 2003 | Decision support system with guideline for managing ischemic heart disease and CHF patients | RCT | Pharmacists, CHF patients | USA, academic primary care practice | Physicians received patient specific feedback; pharmacist system to send feedback to physicians; both | Education + audit and feedback + other (decision support system) | 1 year | Usual care | Mortality, hospitalizations, quality of life, adherence (chart review) | High risk of bias |
Van Bruggen, 2008 | Facilitator enhanced multifaceted intervention for T2D guideline implementation | cRCT | Family doctors and nurses and practice assistants, T2D patients | The Netherlands, primary care practices | Facilitators visited twice a month to train staff on guidelines, performance feedback, | Education + audit and feedback | 1 year | Usual care | Disease target (HbA1c), adherence (prescription and chart review) | Low risk of bias |
Van Steenkiste, 2007 | Decision support tool for risk management improving CVD guideline performance | cRCT | Family doctors, patients without CVD | The Netherlands, hospital | Education, decision support tool, | Other (decision support tool) | 8 months | Educational materials on guideline | Disease target (lifestyle), adherence (chart review) | High risk of bias |
Verweij, 2013 | Effectiveness of guideline based care on weight, CVD risk | cRCT | Occupational physicians | The Netherlands, occupational medicine | Environment scan, patient counselling training, patient toolkit | Other (environment scan, toolkit) | 18 months | Usual care | Quality of life, disease target (BP), adherence (chart review) | High risk of bias |
Education compared to control for improving adherence to cardiovascular disease guidelines | ||||||
---|---|---|---|---|---|---|
Patient or population: patients with improving adherence to cardiovascular disease guidelines | ||||||
Settings: | ||||||
Intervention: Education | ||||||
Comparison: control | ||||||
Outcomes | Illustrative comparative risksa (95 % CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
Assumed risk control | Corresponding risk Education | (95 % CI) | (studies) | (GRADE) | ||
Mortality | Study population | OR 0.54 | 2190 | ⊕ ⊕ ⊕⊝ | ||
Follow-up: median 6 months | 40 per 1000 | 22 per 1000 | (0.2 to 1.42) | (3 studies) | moderatec | |
(8 to 56) | ||||||
Moderate | ||||||
26 per 1000 | 14 per 1000 | |||||
(5 to 37)b | ||||||
Disease Targets | The mean disease targets in the intervention groups was0.32 standard deviations lower | 2145 | ⊕⊝⊝⊝ | SMD −0.32 (−0.71 to 0.07) | ||
Follow-up: 3–6 months | (6 studies) | very lowc,e,f | ||||
(0.71 lower to 0.07 higher) | ||||||
Adherence | The mean adherence in the intervention groups was 0.58 standard deviations higher | 322 | ⊕ ⊕ ⊕⊕ | SMD 0.58 (0.35 to 0.8) | ||
Follow-up: 6–24 months | (4 studies) | high | ||||
(0.35 to 0.8 higher) | ||||||
Mortality | Study population | OR 0.48 | 355 | ⊕ ⊕ ⊝⊝ | ||
Follow-up: 7 months - 10 years | 182 per 1000 | 96 per 1000 | (0.11 to 1.98) | (4 studies) | lowg | |
(24 to 306) | ||||||
Moderate | ||||||
146 per 1000 | 76 per 1000 | |||||
(18 to 253)b | ||||||
Hospitalizations | Study population | OR 0.88 | 979 | ⊕ ⊕ ⊕⊕ | ||
Follow-up: 7–22 months | 188 per 1000 | 170 per 1000 | (0.54 to 1.41) | (4 studies) | high | |
(111 to 246) | ||||||
Moderate | ||||||
191 per 1000 | 172 per 1000 | |||||
(113 to 250)b | ||||||
Disease Targets | The mean disease targets in the intervention groups was 0.09 standard deviations lower | 2732 | ⊕ ⊕ ⊝⊝ | SMD −0.09 (−0.24 to 0.07) | ||
Follow-up: 7–27 months | (5 studies) | lowf,h | ||||
(0.24 lower to 0.07 higher) | ||||||
Adherence | Study population | OR 1.05 | 6019 | ⊕ ⊕ ⊝⊝ | ||
Follow-up: 7–27 months | 609 per 1000 | 620 per 1000 | (0.82 to 1.34) | (8 studies) | lowc,i | |
(561 to 676) | ||||||
Moderate | ||||||
236 per 1000 | 245 per 1000 | |||||
(202 to 293)b | ||||||
Adherence | Study population | OR 2.36 | 2145 | ⊕⊝⊝⊝ | ||
Follow-up: median 6 months | 288 per 1000 | 489 per 1000 | (0.86 to 6.51) | (5 studies) | very lowc,j,k | |
(258 to 725) | ||||||
Moderate | ||||||
326 per 1000 | 533 per 1000 | |||||
(294 to 759)b |