Patient-mediated interventions to improve professional practice

What is the aim of the review?

Our aim with this Cochrane review was to assess whether patients can change the performance of healthcare professionals. We collected and analysed all relevant studies to answer this question and found 25 studies.

Key message

This review suggests that patients may change healthcare professionals’ practice though the following three strategies: 1) strategies where patients give healthcare professionals information about themselves; 2) strategies where patients are given healthcare information; and 3) strategies where patients take part in patient education. Patient decision aids may make little or no difference to healthcare professionals’ practice, however, the certainty is low, and these results should be interpreted carefully. We still need more research about the best ways in which patients can change professional practice and about the impact it has on patients’ health.

What was studied in the review?

Many strategies have been tested to see if they can improve healthcare professionals’ practice and make sure that patients receive the best available care. These strategies include sending reminders to healthcare professionals, giving them further education, or giving them financial rewards. These strategies have mostly had only small or moderate effects. Another way of changing what healthcare professionals do is through the patients themselves. These strategies are called 'patient-mediated interventions'.

What are the main results of the review?

The studies in this review assessed different patient-mediated strategies compared to usual care or no strategies.

Strategies where patients give information to healthcare professionals

In these studies, patients gave information about their own health, concerns or needs to the doctor. This was usually done by filling in a questionnaire in the waiting area before a consultation. The doctor was then given this information before or at the consultation. The review shows that these strategies:

- probably improve the extent to which healthcare professionals follow recommended clinical practice (moderate-certainty evidence).

We are uncertain about the effect of these strategies on patient health, patient satisfaction and resource use because these outcomes were not measured in the studies or because the certainty of the evidence is very low.

Strategies where information was given to patients

In these studies, patients were given information about recommended care or were reminded to use services, for instance to go for a check-up. The review shows that these strategies:

- may improve the extent to which healthcare professionals follow recommended clinical practice (low-certainty evidence);

- may have little or no effect on patient satisfaction (low-certainty evidence);

- may have little or no effect on some patient health outcomes, such as the number of patients who reach controlled blood pressure (low-certainty evidence). However, we are uncertain about the effect of these strategies on other patient health outcomes because the certainty of the evidence is very low. We also lack information to draw conclusions about resource use.

Patient education strategies

In these studies, patients took part in patient education such as self-management programmes, for instance to increase their knowledge about their condition. The review shows that these strategies:

- probably improve the extent to which healthcare professionals follow recommended clinical practice (moderate-certainty evidence);

- may slightly improve some patient health outcomes such as the number of patients who reach controlled blood pressure (low-certainty evidence). However, we are uncertain about the effect of these strategies on other patient health outcomes, patient satisfaction and resource use because these outcomes were not measured in the included studies.

Patient decision aid strategies

In the one study that assessed effect of patient decision aids, patients were given a decision aid consisting of a booklet, personal worksheet, and audiotape to make decisions about their medical management. The review shows that these strategies:

- may have little or no effect on the extent to which healthcare professionals follow recommended clinical practice (low-certainty evidence)

We are uncertain about the effect of these strategies on patient health, patient satisfaction and resource use because these outcomes were not measured in the studies or because the certainty of the evidence is very low.

How up-to-date is this review?

We searched for studies up to March 2018 and ongoing studies up to October 2017.

Authors' conclusions: 

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).

The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

Read the full abstract...
Background: 

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

Objectives: 

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

Search strategy: 

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

Selection criteria: 

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

Data collection and analysis: 

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

Main results: 

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.

Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.

Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.

Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

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