Improving the uptake of cardiac rehabilitation in invited patients: a multi-method evaluation
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Cardiac rehabilitation (CR) can reduce mortality and morbidity through assisting patients in regaining physical and psychosocial well-being. CR is effective yet uptake rates are 44%. Of non-attenders, 30% expressed a ‘lack of interest’; the focus of this thesis’ question ‘What strategy would improve uptake of CR in invited patients.’
A sequential, multi-method approach was used. Literature reviews, assessing strategies to increase CR uptake and participation in other health services, found similar intervention designs, such as peers or health behaviour theory-based (HBT). An e-survey explored invitation strategies in CR practice and confirmed letters are used and low-cost. An advancement of theory-based letters is valuable but little is known about the operationalisation of HBT. Telephone interviews were conducted to explore the latter through patients’ viewpoints. A quasi-experiment evaluated the amended letters.
One review found six RCTs testing peer support, professional support (or combined) and letters, the latter two increased attendance. Twenty-three reviews on strategies promoting participation support access-enhancing methods, organisational changes, letters and calls. 190 CRPs indicated that multiple invitation strategies including in- hospital (70%), telephone (70%), letters (50%) are used; variations exist. Feasibility considerations supported the development of existing HBT letters. Interviews revealed a preference for less authoritative content outlining positive effects. Of 6 sites, with different organisational structure, 1 increased CR uptake using the new letter.
The amended theory-based letter had limited impact in CR uptake perhaps due to extrinsic factors, the letter itself or methodological issues. CR is a fragmented service and results highlight the importance of context-sensitive policies.Keywords:
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Many current research needs can only be addressed using very large cohorts. In such studies, traditional one-on-one phone, face-to-face, or paper-based engagement may not be feasible. The only realistic mechanism for maintaining engagement and participation at this scale is via digital methods. Given the substantial investment being made into very large birth cohort studies, evidence for optimal methods of participant engagement, participation, and retention over sustained periods without in-person contact from researchers is paramount.This study aims to provide an overview of systematic reviews and meta-analyses evaluating alternative strategies for maximizing participant engagement and retention rates in large-scale studies using digital methods.We used a rapid review method by searching PubMed and Ovid MEDLINE databases from January 2012 to December 2019. Studies evaluating at least 1 e-engagement, participation, or retention strategy were eligible. Articles were screened for relevance based on preset inclusion and exclusion criteria. The methodological quality of the included reviews was assessed using the AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews 2) measurement tool, and a narrative synthesis of the data was conducted.The literature search yielded 19 eligible reviews. Overall, 63% (n=12) of these reviews reported on the effectiveness of e-engagement or participation promotion strategies. These evaluations were generally not conducted within very large observational digital cohorts. Most of the contributing reviews included multipurpose cohort studies (with both observational and interventional elements) conducted in clinical and research settings. Email or SMS text message reminders, SMS text messages or voice notifications, and incentives were the most commonly used design features to engage and retain participants. For parental outcomes, engagement-facilitation interventions influenced uptake and behavior change, including video feedback, goal setting, and intensive human facilitation and support. Participant-stated preferences for content included new knowledge, reminders, solutions, and suggestions about health issues presented in a clear, short, and personalized way. Perinatal and postpartum women valued self-monitoring and personalized feedback. Digital reminders and multiple SMS text messages were specific strategies that were found to increase adherence to medication and clinic attendance, respectively.This review adds to the growing literature evaluating methods to optimize engagement and participation that may apply to large-scale studies using digital methods; it is promising that most e-engagement and participation promotion strategies appear to be effective. However, these reviews canvassed relatively few strategies, suggesting that few alternative strategies have been experimentally evaluated. The reviews also revealed a dearth of experimental evidence generated within very large observational digital cohort studies, which may reflect the small number of such studies worldwide. Thus, very large studies may need to proactively build in experimental opportunities to test engagement and retention approaches to enhance the success of their own and other large digital contact studies.
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Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems.The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care.This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered.The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded.Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute.Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute.The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated.Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process.There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.
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Background: Reducing stroke related mortality and morbidity is a Government priority. In 2007, the National Stroke Strategy recommended reviewing stroke survivors at six weeks, six months and annually thereafter but there is much variation in implementation and limited evaluation. While there is evidence of unmet need post-stroke there is little evidence to suggest that the review process ameliorates it.
This study aimed to identify the purpose and outcomes of the review process from the perspective of patient, carer, provider and commissioner and to identify the mechanisms by which these were achieved. As many patients are still engaged in rehabilitation at six weeks post-stroke, a six-week review is of less significance than a six-month one by when services have usually withdrawn and patients report feeling abandoned. The annual review is not widely available and therefore this study concentrates on the six-month review.
Method: A multiple case study approach underpinned by critical realism informed the research design and allowed in-depth exploration of the six-month review. Case studies draw on multiple sources of evidence to allow triangulation, develop convergent evidence and thus strengthen construct validity. Three sites in the South East Coast region were chosen for their different approaches set within the context of local policies and demographics. Data sources included interviews with patients, carers, providers who carried out reviews, service managers and commissioners; observations in clinical settings; and local policy and service documentation. This allowed multiple perspectives in order to explore the underlying mechanisms of the review. Patients were interviewed approximately six weeks post-discharge and again after their six-month review. Overall, 46 patients, 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty-nine reviews were observed. The age range of patients was 28-91 years and slightly more than half were male.
Data analysis drew on three approaches selected for a particular strength: thematic analysis was chosen for its clear and succinct account of coding and epistemologically neutral stance (Braun and Clarke 2006); Yin's (2014) case study analysis provided helpful suggestions for theory development; and Bazeley's (2013) comprehensive text provided a model for analysis and theory development compatible with critical realism. Data was managed using Nvivo 11. Within each site, all data sources were coded in an iterative process to develop the coding framework and an understanding of site specific issues. Data was then explored across sites before building a typology of patients in order to develop a theoretical understanding of the review process that could be extended to a broader context.
Findings: Six-month reviews carried out by stroke nurse specialists were found to be more medically orientated than those completed by a Stroke Association co-ordinator who focused on social issues. Reviewers regarded them as an opportunity to address unmet need but expressed different opinions as to what this encompassed. Managers and commissioners were mainly concerned with outcomes focused on (cost-) effectiveness. Patients' views were influenced by their experiences of the care pathway, orientation to rehabilitation and the nature of their relationships with clinicians during their rehabilitation. Those who reported a positive experience of care and took a proactive approach to rehabilitation were likely to self-manage their condition and find the review helpful. Their comments emphasised that they valued reassurance, information and advice. A second group was positive about rehabilitation but largely on their own terms and rejected advice from reviewers. Finally, a small number who did not find the review helpful had pre-existing long-term conditions and/or complex social circumstances. They were critical of services, did not trust reviewers or clinicians in general, and were focused on issues outside the remit of the review.
Discussion: The medical and social paradigms which framed the review process each had their own strengths but some patients, particularly those with complex social circumstances and co-morbidities, needed elements of both within an individually tailored approach. There was a tension between the structure imposed by policy and the agency and wish of reviewers and patients to individualise the process. Encouraging self-management was a key aspect of the review but was limited by the nature of the intervention and gaps in community services. The review acted as a gateway to further services, for example clinical psychology, although such services were not always available.
Recommendations: The six-month review needs to be embedded into the care pathway and strategies for secondary prevention reviewed and consolidated at each stage. Reviewers should be allowed the freedom to individualise the process on a needs-led basis rather than adhering to a rigid framework dictated by policy. The six-month review ought to relate back to therapy goals and forward to community services to encourage participation in valued activities, and community integration, which are the key goals of rehabilitation.
Stroke
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Background: Ensuring adequate, informed, and timely participation in clinical trials is a multifactorial problem. We have previously developed a systematic, tailorable survey development approach that is informed by theory, can identify barriers and enablers to participation, and can suggest recruitment strategies to address these issues. In this study, we surveyed subscribers to the Canadian Breast Cancer Network (CBCN) in order to identify a comprehensive list of theory-informed barriers and enablers relevant to participation in a hypothetical breast cancer trial. Methods: We developed and conducted an online survey of breast cancer patients informed by the Theoretical Domains Framework and designed to determine previous experience with clinical trials, knowledge about clinical trials, and importance of a comprehensive list of barriers and enablers to trial participation. Participants were contacted by email or through social media. Results: From 2451 subscribers of the CBCN, we received 244 responses and 210 completed surveys (244/2451 or 9.9% participation, 210/244 or 86.1% completion). A total of 38% of respondents indicated experience in trial participation, but 83% indicated confidence in their knowledge about clinical trials. Those who had previously participated in clinical trials were more confident in their knowledge (χ2= 6.77, p = 0.009) and answered more knowledge questions (t = −3.90 p = 0.000). Endorsed barriers and enablers to participation included 39 factors across 12 of 14 domains relevant to behaviour change. Our approach identifies barriers that might be meaningfully addressed by careful knowledge provision (‘If I would learn more about my condition’; ‘If I find the trial documents hard to understand’), those that may require other theory-informed approaches to address (‘my feelings about the quality of my drug plan’; ‘my worry over unknown side effects’), and those that may require tailored approaches depending on participant differences such as previous experience in trials (‘If there were patient-friendly decision-making tools to help you make your participation decision’). Discussion: This work demonstrates that a comprehensive, theory-guided survey of barriers and enablers to participation in breast cancer clinical trials is feasible, can lead to detailed knowledge about the issues related to participation in specific trials, and most importantly, can lead to insights about evidence-based ways to better support patient participation.
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Objectives (i) To synthesise the evidence-base for Schwartz Center Rounds (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds. Design Systematic review of Rounds literature; scoping reviews of comparator interventions (action learning sets; after action reviews; Balint groups; caregiver support programme; clinical supervision; critical incident stress debriefing; mindfulness-based stress reduction; peer-supported storytelling; psychosocial intervention training; reflective practice groups; resilience training). Data sources PsychINFO, CINAHL, MEDLINE and EMBASE, internet search engines; consultation with experts. Eligibility criteria Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English. Results The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (10 studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders. Conclusions Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace well-being arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the well-being of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff well-being.
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Background It is often assumed that merely providing information in an accessible form will influence practice. Although such a strategy is still widely used in an attempt to change behaviour, there is a growing awareness that simply providing information may not lead to appropriate changes in the practice of health care professionals.Objectives To assess the effects of printed educational materials in improving the behaviour of health care professionals and patient outcomes.Search strategy We searched the Cochrane Effective Practice and Organisation of CareGroup specialised register, reference lists of articles, and contacted content area experts.Selection criteria Randomised trials, interrupted time series analyses and non equivalent group designs with pre- post measures of interventions comparing 1. Printed educational materials versus a non-intervention control; and 2. Printed educational materials plus additional implementation strategies versus printed educational materials alone. The participants were any health care professionals provided with printed educational materials aimed at improving their practice and/or patient outcomes.Data collection and analysis Two reviewers independently extracted data and assessed study quality.Main results Eleven studies were included involving more than 1848 physicians. It proved impractical to examine the impact of interventions quantitatively because of poor reporting of results and inappropriate primary analyses. Nine studies examined comparison 1. Estimates of the benefit from printed educational materials ranged from -3% to 243.4% for provider outcomes, and from -16.1% to 175.6% for patient outcomes, although the practical importance of these changes is, at best, small. Six studies (seven comparisons) examined comparison 2. Benefits attributable to additional interventions ranged from - 11.8% to 92.7% for professional behaviour, and - 24.4% to 74.5% for patient outcomes. Two of the 14 estimates of professional behaviour, and two of the 11 estimates of patient outcomes were statistically significant.Authors' conclusions The effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved. Authors' conclusions The effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved.
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Objectives During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions. Design Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients. Setting Thirty-three UK general practices in three areas. Participants The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview. Results Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from ‘tick-box’ to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns. Conclusions Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention. Trial registration number ISRCTN06180958
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Background Offender health is deemed a priority issue by the Department of Health. Peer support is an established feature of prison life in England and Wales; however, more needs to be known about the effectiveness of peer-based interventions to maintain and improve health in prison settings. Objectives The study aimed to synthesise the evidence on peer-based interventions in prison settings by carrying out a systematic review and holding an expert symposium. Review questions were (1) what are the effects of peer-based interventions on prisoner health and the determinants of prisoner health?, (2) what are the positive and negative impacts on health services within prison settings of delivering peer-based interventions?, (3) how do the effects of peer-based approaches compare with those of professionally led approaches? and (4) what are the costs and cost-effectiveness of peer-based interventions in prison settings? Data sources For the systematic review, 20 electronic databases including MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature and EMBASE were searched from 1985. Grey literature and relevant websites were also searched. To supplement the review findings 58 delegates, representing a variety of organisations, attended an expert symposium, which provided contextual information. Review methods Two reviewers independently selected studies using the following inclusion criteria: population – prisoners resident in prisons and young offender institutions; intervention – peer-based interventions; comparators: review questions 3 and 4 compared peer-led and professionally led approaches; outcomes – prisoner health or determinants of health, organisational/process outcomes or views of prison populations; study design: quantitative, qualitative and mixed-methods evaluations. Two reviewers extracted data and assessed validity using piloted electronic forms and validity assessment criteria based on published checklists. Results from quantitative studies were combined using narrative summary and meta-analysis when appropriate; results from qualitative studies were combined using thematic synthesis. Results A total of 15,320 potentially relevant papers were identified of which 57 studies were included in the effectiveness review and one study was included in the cost-effectiveness review; most were of poor methodological quality. A typology of peer-based interventions was developed. Evidence suggested that peer education interventions are effective at reducing risky behaviours and that peer support services provide an acceptable source of help within the prison environment and have a positive effect on recipients; the strongest evidence came from the Listener scheme. Consistent evidence from many predominantly qualitative studies suggested that being a peer deliverer was associated with positive effects across all intervention types. There was limited evidence about recruitment of peer deliverers. Recurring themes were the importance of prison managerial and staff support for schemes to operate successfully, and risk management. There was little evidence on the cost-effectiveness of peer-based interventions. An economic model, developed from the results of the effectiveness review, although based on data of variable quality and a number of assumptions, showed the cost-effectiveness of peer-led over professionally led education in prison for the prevention of human immunodeficiency virus (HIV) infection. Limitations The 58 included studies were, on the whole, of poor methodological quality. Conclusions There is consistent evidence from a large number of studies that being a peer worker is associated with positive health. Peer support services can also provide an acceptable source of help within the prison environment and can have a positive effect on recipients. This was confirmed by expert evidence. Research into cost-effectiveness is sparse but a limited HIV-specific economic model, although based on a number of assumptions and evidence of variable quality, showed that peer interventions were cost-effective compared with professionally led interventions. Well-designed intervention studies are needed to provide robust evidence including assessing outcomes for the target population, economic analysis of cost-effectiveness and impacts on prison health services. More research is needed to examine issues of reach, utilisation and acceptability from the perspective of recipients and those who choose not to receive peer support. Study registration This study was registered as PROSPERO CRD42012002349. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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This study aimed to (i) explore occupational therapy practitioners' perceptions of the scope and sources of evidence that they use in clinical decision-making; and (ii) identify strategies and resources that would increase the use of evidence in a paediatric clinical service.An action research methodology was applied to systematically explore participants' experiences of using evidence in practice and to democratically develop ways of increasing evidence-based practice. A series of six focus groups were conducted with nine occupational therapists, whose clinical experience ranged from 5 to 24 years. All participants had completed or were undertaking research qualifications. A systematic process of data coding was used whereby data were coded, categorised, analysed thematically and summaries developed. Rigour was maintained through triangulation (i.e. multiple data sources and occasions of data collection), and consultation and interpretation by two researchers.Participants identified two distinct sources of evidence they use in clinical practice: research-based and practice-based. They identified features of each source that they valued but also described barriers to the utilisation of each. Participants proposed strategies to increase the value of each source of evidence in their clinical practice. Strategies included appraising the clinical relevance and utility of research-based evidence, and developing standards and systematic processes to increase the credibility of practice-based evidence.Participants in this study perceived that although it is necessary to use all the available evidence in practice settings, there are currently barriers to using both research-based and practice-based evidence. In particular, the study indicates that there is need for the development of a structured model with processes and standards to guide practitioners in the collection, trial, evaluation and dissemination of practice-generated evidence. Further research is needed to explore the extent to which valid evidence can be generated from individual client programs by examining therapists' strategies for goal attainment in practice settings.
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Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. This review had three goals: (1) assess the effectiveness of quality improvement, implementation, and dissemination strategies intended to improve the mental health care of children and adolescents; (2) examine harms associated with these strategies; and (3) determine whether effectiveness or harms differ for subgroups based on system, organizational, practitioner, or patient characteristics. Sources included MEDLINE®, the Cochrane Library, PsycINFO, and CINAHL, from database inception through February 17, 2017. Additional sources included gray literature, additional studies from reference lists, and technical experts. Two reviewers selected relevant randomized controlled trials (RCTs) and observational studies, extracted data, and assessed risk of bias. Dual analysis, synthesis, and grading of the strength of evidence for each outcome followed for studies meeting inclusion criteria. We also used qualitative comparative analysis to examine relationships between combinations of strategy components and improvements in outcomes. We identified 18 strategies described in 19 studies. Eleven strategies significantly improved at least one measure of intermediate outcomes, final health outcomes, or resource use. Moderate strength of evidence (from one RCT) supported using provider financial incentives such as pay for performance to improve the competence with which practitioners can implement evidence-based practices (EBPs). We found inconsistent evidence involving strategies with educational meetings, materials, and outreach; programs appeared to be successful in combination with reminders or providing practitioners with newly collected clinical information. We also found low strength of evidence for no benefit for initiatives that included only educational materials or meetings (or both), or only educational materials and outreach components. Evidence was insufficient to draw conclusions on harms and moderators of interventions. Several strategies can improve both intermediate and final health outcomes and resource use. This complex and heterogeneous body of evidence does not permit us to have a high degree of confidence about the efficacy of any one strategy because we generally found only a single study testing each strategy. PROSPERO, CRD42015024759 .
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