Behavior change interventions and policies influencing primary healthcare professionals’ practice—an overview of reviews

1Approximately one in six Canadians aged 20 years or older suffer from chronic diseases such as diabetes, cardiovascular diseases, chronic respiratory diseases, arthritis, osteoporosis, mental illness, and cancer. Combining direct medical costs ($38.9 billion) and indirect productivity losses ($54.4 billion), the total economic burden of chronic illness exceeds Canadian $93 billion a year. Despite this enormous expenditure, 12 to 15% of Canadians feel they receive inadequate chronic disease care. The major unmet needs include long waiting periods for medical services and unavailability of essential services. Compared with people in other developed nations, Canadians today are less satisfied with their access to and quality of care and have worse health outcomes for several medical conditions. The numbers of patients with chronic diseases and the existing gap in quality of care present a significant challenge for public health policy-makers.

2With the objective of closing gaps in quality of care and managing patients with chronic diseases, the implementation of patient-centred treatment has recently gained attention from policy-makers. Patient-centered medical centres may become the future backbone of the Canadian healthcare system. These teams may include family physicians, physician assistants, nurses, pharmacists, social workers, mental health counselors/psychologists, dieticians, and midwives among others. To achieve efficient and effective patient-centered medical homes, some changes in the way healthcare is delivered will be required. To do so, effective behavior change interventions and supporting policies are required. However, it is unclear which intervention(s) and policies are appropriate, sustainable, and sufficiently safe to support practice change and improve patient-relevant outcomes in primary healthcare settings. Despite extensive published literature including randomized controlled trials, observational studies, and systematic reviews, no recent comprehensive review classifying or evaluating the feasibility or effectiveness of interventions and policies in terms of patients’ and professionals’ outcomes exists. The objectives of this overview of reviews were to identify, classify, and critically appraise reviews evaluating behavior change interventions and policies influencing primary healthcare professionals working at primary healthcare centers.

3The search strategy was developed and tested through an iterative process by an experienced medical information specialist in consultation with the review team. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EbscoHost), and the Cochrane Library (Wiley). Strategies utilized a combination of controlled vocabulary (e.g., “Physicians", "Primary Care”, “Physician’s Practice Patterns”, “Quality Improvement”) and keywords (e.g., family practitioner, home clinic, policy adherence). Vocabulary and syntax were adjusted across databases. Results were restricted to the English language and the dates from January 2005 to July 2015 (Additional file 1). We used DistillerSR (Version 2, Evidence Partners Inc. ON, Canada) for study selection, data extraction, and project management.

4We included (1) systematic reviews, overview of reviews, scoping reviews, rapid reviews, or health technology assessments that (2) evaluated behavior change interventions or policies on primary healthcare professionals (including general practitioners/family physicians, physician assistants, nurses, pharmacists, social workers, mental health counselors/psychologists, dieticians, and midwives) (3) working at primary healthcare settings (4) reporting any outcomes of primary healthcare professionals’ practice change, and (5) published in the English language as full-text articles. Primary healthcare settings were defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Considering the application of outcomes in the Canadian context, reviews that exclusively included studies conducted in either underdeveloped or developing countries were excluded.

5The abstracts and titles of relevant citations were independently screened by two reviewers to determine eligibility. The same two reviewers independently assessed the eligibility of full-text reports of relevant citations using a standardized pre-piloted form outlining the inclusion and exclusion criteria. Disagreements were resolved by consensus or with the involvement of a third reviewer, if needed.

6Two reviewers independently abstracted data from the included reviews using standardized piloted forms. The following data were extracted from each included review: review type, number and study designs that the review included, types of professionals evaluated, interventions, outcomes, therapeutic domains, and authors’ conclusions.

7All behavior change interventions and policies were classified into nine categories of interventions and seven categories of policies following the behavior change wheel framework proposed by Michie et al.. This framework consists of a behavior system at the hub, encircled by nine intervention functions and then by seven policy categories. The nine behavior change interventions include (1) education (increasing knowledge or understanding): e.g., continuous medical education; (2) persuasion (using communication to induce positive or negative feelings or stimulate action): e.g., reminders; (3) incentivization (creating expectation of reward): e.g., payment for performance; (4) coercion (creating expectation of punishment or cost): e.g., punishment or fines; (5) training (imparting skills): e.g., communication skills training; (6) restriction (using rules to reduce the opportunity to engage in the target behavior): e.g., rules for prohibiting the use; (7) environmental restructuring (changing the physical or social context): e.g., shared decision-making; (8) modeling (providing an example for people to aspire to or imitate): e.g., local opinion leaders; (9) enablement (increasing means/reducing barriers to increase capability or opportunity): e.g., clinical decision support systems. While the seven policies include: (1) communication/marketing (using print, electronic, telephonic or broadcast media): e.g., advertising media; (2) guidelines (creating documents that recommend or mandate practice): e.g., management guidelines; (3) fiscal (using the tax system to reduce or increase the financial cost): e.g., financial provisions from policy-makers; (4) regulation (establishing rules or principles of behavior or practice): e.g., rules and regulations; (5) legislation (making or changing laws): e.g., law amendments; (6) environmental/social planning (designing and/or controlling the physical or social environment): e.g., social support; (7) service provision (delivering a service): e.g., service or facilitation.

8Two reviewers independently, and in duplicate, evaluated the methodological quality of the included reviews using the assessing the methodological quality of systematic reviews (AMSTAR) scoring system. Conflicts were resolved by consensus or discussion with a third reviewer, if needed. Reviews with AMSTAR score ≥8, 4 to 7, ≤3 were considered as high, moderate, or low-methodological quality, respectively.

9We summarized the findings that emerged from the subjective judgment matrix, which was based on the authors’ conclusions, qualitative data, quantitative data with statistically significant group differences in terms of patients’ and primary healthcare providers’ outcomes, and the methodological quality of included reviews. The protocol for this overview of reviews has been developed prior to conduct the review and provided to the Primary Health Care Branch, Manitoba Health, Seniors and Active Living, Government of Manitoba, Canada. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting the systematic review were followed.

10We screened 2771 citations and included 138 reviews representing 3502 individual studies (Fig. 1). The characteristics of the included reviews are presented in Table 1. Of the included studies, three were overviews of reviews. Most reviews (91%) investigated behavior change interventions and policies among family physicians primarily managing chronic diseases at primary healthcare centers. We classified the included reviews into eight of nine categories of behavior change interventions including education (n = 28, 20%), enablement (n = 16, 12%), environmental restructuring (n = 18, 13%), incentivization (n = 7, 5%), modeling (n = 2, 2%), multiple interventions (n = 42, 30%), persuasion (n = 4, 3%), training (n = 11, 8%), and three of seven categories of policies including service provision (n = 5, 4%), communications (n = 3, 2%), and guidelines (n = 2, 2%). Major chronic diseases evaluated were mental disorders (n = 12, 9%), diabetes (n = 10, 7%), respiratory diseases (n = 8, 6%), cancer (n = 5, 4%), cardiovascular diseases (n = 4, 3%), arthritis/osteoporosis (n = 3, 2%), and hypertension (n = 2, 2%); some reviews reported more than one chronic disease. Total of 36 (26%) reviews exclusively included randomized controlled trials. The remaining reviews included systematic reviews, observational studies, interrupted time series studies, and controlled before-after studies (Table 1). Of the total included reviews, 68 (49%) reviews were of high quality, 60 (44%) reviews were of moderate quality, and 11 (8%) reviews were of low quality (Additional file 1: Table S1).

11Twenty-eight reviews (n = 509 studies) evaluated educational interventions. Evidence from moderate- to high-quality reviews demonstrated that education to improve knowledge and skills, continuing medical education, and academic detailing were found to be effective in professional development to increase knowledge, optimize prescriptions, screening rate, and improve patient outcomes. Certain education interventions were evaluated as components of multifaceted education interventions, including interactive educational methods, reminder systems, audit and feedback, academic detailing, computer-based learning, lecture, as well as pamphlet in several reviews; which reported improvement in implementing guidelines into general practice, improved antibiotic prescribing, improved detection of cancer, dementia, and skin lesions. Conflicting evidence exists on patient feedback. One review, based on ten studies, reported some evidence for the effectiveness of using feedback from real patients to improve knowledge and primary healthcare professionals’ practice change exists while other reviews failed to reach the same conclusion.

12Sixteen reviews (n = 377 studies) evaluated the use of information technologies including interactive analysis systems, clinical decision support systems, electronic health records and prescriptions, and point of care testing to increase capability and facilitate practice change of primary healthcare professionals. Evidence from moderate- to high-quality reviews demonstrated that enablement interventions improved communication between healthcare professionals and patients, augmented knowledge, facilitated the appropriate antibiotic prescriptions, increased quality of service, reduced potential adverse events (drug interactions, contraindications, dose monitoring, and adjustment), and improved several patient outcomes.

13Nineteen (n = 470 studies) evaluated the impact of environmental restructuring including the use of collaborative or shared care practices or the institution of specialized nurses or other allied healthcare professionals, or guideline implementation in primary healthcare settings. Evidence from poor- to high-quality reviews indicate organizational changes to increase collaboration among pharmacists, nurses, prevention coordinators, and other primary healthcare professionals led to increased physicians’ adherence to guidelines. Nurse-led care was found to be as equally effective as general practitioners in patient satisfaction, asthma, cardiovascular, and diabetes management. However, weak study designs and restricted interventional scopes mean that further evaluation is required, especially in the context of other chronic diseases.

14Seven reviews (n = 198 studies) evaluated the impact of financial incentives on family physicians. All reviews of poor- to high-quality failed to provide supportive evidence of any significant improvement in family physicians’ behavior change. One high-quality review observed modest improvements in quality of care for chronic diseases, albeit, the impact on costs, professional behavior, and patient experience remained uncertain.

15Two reviews (n = 60 studies) evaluated modeling using local opinion leaders, or mental health workers in primary healthcare settings. Evidence from moderate- to high-quality reviews demonstrated that involving local opinion leaders or subject experts to promote evidence-informed practices decreased the rates of consultations and prescriptions.

16Four reviews (n = 218 studies) reported on interventions categorized as persuasion. Evidence from moderate- to high-quality reviews indicates that reminders worked well to reduce unnecessary imaging for lower back pain while improving the rate of screening and vaccination.

17Eleven reviews (n = 165 studies) focused on training. Evidence from moderate- to high-quality reviews reported that training on communication skills and cultural competency improved knowledge and professional expertise, which resulted in improved clinical outcomes including quality of life, well-being of patients with dementia, and reduced chronic disease in culturally and linguistically diverse communities.

18Several reviews were focused on how to better manage chronic diseases using any behavior change interventions. To avoid misclassification, we classified these reviews under an umbrella term, multiple interventions. Forty-one reviews (n = 1375 studies) of poor- to high-quality focused on multiple interventions. The use of computer alerts within electronic medical records increased screening for sexually transmitted diseases. Interventions in pharmacy services reduced suboptimal prescribing, and educational interventions improved primary healthcare providers’ identification, assessment, prevention and/or management of obesity in children and adolescents to achieve weight loss. No review focused exclusively on audit and feedback, but multifaceted audit/feedback, reminders, educational outreach visits, and patient-mediated interventions were found to be effective in influencing health professionals’ prescribing practice. Financial incentives combined with educational interventions and audit/feedback have been found to be effective in increasing the practice of generic prescribing. Multifaceted interventions where educational interventions occurred at many levels may be successfully incorporated into established medical communities after addressing local barriers to change. Advance practice nurse care, quality improvement strategies, case management, collaborative care, evidence-based medicine practice strategies, midwife-led continuity services, comprehensive asthma care, and patient-centered medical home have all been evaluated. Moderate- to high-quality reviews demonstrated improved safety, quality care, increased vaccination rate, and improved management of patient with depression and anxiety in primary healthcare settings. Few reviews failed to provide any conclusive outcomes.

19Five reviews (n = 44 studies) of poor- to high-quality evaluated effects of consultation time, brief non-pharmacological interventions (computer-based cognitive-behavioral therapy), and non-medical prescribing (drug prescriptions by nurses, pharmacists, and allied health professionals) on behavioral change of primary healthcare professionals. While a health technology report assessed evidence on specialized community-based care and concluded that specialized community-based care effectively improves outcomes in patients with heart failure, chronic obstructive pulmonary disease, and diabetes. Bibliotherapy, cognitive behavioral therapy-based websites, and cognitive behavioral therapy-based computer programs found to be effective in improving management of patients with depression. Other reviews were not found to be effective.

20Three reviews (n = 44 studies) of moderate- to high-quality evaluated communication as an intervention reporting inconclusive results. One review uniquely assessed whether patients benefit from improved communication between primary healthcare practitioners and nephrologists. The review found little evidence of benefit from enhancing the quality of letters from specialists to primary healthcare practitioners.

21Two reviews (n = 42 studies) of moderate- to high-quality evaluated the impact of guidelines on the improvement of healthcare professionals’ practice. None of the interventions found to be effective method for increasing advance directive completion rates in the primary healthcare setting.

22In our overview of reviews, we identified, classified, and evaluated the behavior change interventions and policies influencing practice change of primary healthcare professionals who primarily manage patients with chronic diseases at primary healthcare centers. Interactive and multifaceted continuous medical education programs including training with audit and feedback, and clinical decision support systems were found to be of benefit in improving knowledge, optimizing prescriptions, increasing screening rate, enhancing patient outcomes, and reducing adverse events. Limited evidence on environmental restructuring and modeling were found to be effective in improving collaboration and adherence to treatment guidelines. Collaborative team-based approaches involving primarily family physicians, nurses, and pharmacists were found to be effective. Limited evidence on nurse-led care approaches were found to be promising and warrant further evaluation using better study designs for different chronic diseases. Evidence clearly does not support the use of financial incentives to family physicians, especially for long-term sustained behavior and practice change.

23To the best of our knowledge, so far this is the largest comprehensive overview of reviews evaluating authors’ reported efficacy of behavior change interventions and policies influencing primary healthcare professionals’ practice change and classified according to the behavior change wheel proposed by Michie et al.. Our outcomes support the inferences reported by other overview reviews and review focused on individual interventions. Grimshaw and colleagues reported that educational outreach (for prescribing) and reminders were found to be most promising approaches. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. We reported that education intervention found to be effective, especially when used as multifaceted interventions to achieve primary healthcare professionals’ practice change to improve quality of care and better manage patients with chronic diseases. Ivers and colleagues reported audit and feedback generally leads to small but potentially important improvements in professional practice. We did not find any review exclusively evaluating audit and feedback on primary healthcare professionals; however, it was used with other interventions (e.g., education and training) and provided mixed results. With regards to financial incentives, Flodgren and colleagues have reported that financial incentives may be effective in changing healthcare professional practice. In contrast, we found that financial incentives were not effective in practice change of family physicians working at primary healthcare centers.

24This review did identify limited evidence on a few promising interventions, including nurse-led approaches and use of opinion leaders or specialists. Further, thorough evaluation in specific areas of interest should be performed before they are widely implemented in a healthcare setting.

25To reduce the gap in quality of care and better manage patients with chronic diseases, behavioral interventions and supporting policies are essential. Through this overview of reviews, we attempted to provide an evidence to improve our understanding on which behavioral interventions and policies are effective to influence practice of primary healthcare professionals working in primary health care settings. This review is heavily weighted by evidence on family physicians, thus indicating the need for studies on other primary healthcare professionals. We excluded reviews that either evaluated these interventions and policies on specialists and hospital settings or included studies conducted exclusively in low- to middle-income countries, where the functionality of healthcare systems is different than Canada. Behavior change interventions or policies were classified based on the framework proposed by Michie and colleagues and no other frameworks were explored or compared. Considering this is an overview of reviews and we have not performed a meta-analysis, we did not attempt to review individual studies from included reviews; there is a possibility of few studies might have been included by multiple reviews or might be a chance of over representation of outcomes. Evidence ranged from poor- to high-quality as well the high heterogeneity in interventions, study population, and outcomes prevented to generalize the conclusion to specific category of primary healthcare professionals or interventions and policies.

26Behavior change interventions including interactive and multifaceted continuous medical education, training with audit and feedback, enablement through advanced information technology-based systems, and collaborative team-based interventions can effectively modify healthcare professionals’ practice and patient outcomes. Limited evidence exists to support environment restructuring and modeling. Nurse-led systems of care warrant further evaluation. Financial incentives to family physicians do not influence long-term behavior and practice change.