EBP Research Table Assignment

EBP Research Table Assignment

EBP Research Table Assignment

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Week 5 assignment CLC: EBP Research Table Citation Include the APA reference note. Abstract/Purpose Craft a 100-150 word summary of the research. Research/Study Describe the design of the relevant research or study in the article. Methods Describe the methods used, including tools, systems, etc. Setting/Subject Identify the population and the setting in which the study was conducted. Findings/Results Identify the relevant findings, including any specific data points that may be of interest to your EBP project. Variables Describe the independent and dependent variables in the research/study. Implication for Practice Articulate the value of the research to the EBP project your group has chosen. Independent Variable Dependent Variable

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Evidence Table
Evidence-Based Practice in Nursing
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Source
Issue Related to EBP
Design Type*
Study Design & Study Outcome Measure(s)
Study Setting & Study Population
Study Intervention
Key Findings
Berner 2003121
Local opinion leaders.
Group randomized controlled trial (RCT). Evidence level 2.
RCT 3 study arms: no intervention, traditional health care QI; opinion leader (OL) plus QI (level 2). Outcomes = 6 evidence-based quality indicators for 1994 unstable angina guidelines (level 2).
Hospitals in Alabama. Patients admitted to an Alabama hospital during 1997–98 (baseline) and 1999–2000 (followup) with ICD-9 CM codes of unstable angina, angina pectoris, coronary artery disease, and chest pain unspecified. Mean age of patients was >70 years of age.
Peer nominated opinion leader added to a Centers for Medicare and Medicaid Services (CMS) QI intervention.
OL treatment effects (over QI group) found for antiplatelet medication within 24 hours and heparin use (2 of 5 indicators).
Bootsmiller 2004103
Assess the implementation methods for 4 clinical practice guidelines (CPGs) in the VA health care system.
Retrospective cohort study. Evidence level 5.
Survey methods with questionnaire sent to 416 quality managers, primary care administrators, or others involved with guideline implementation in primary care at 143 VA medical centers with primary care clinics (level 9). Modified Dillman method was used.
Outcomes: methods used to implement guidelines (level 4).
Primary care clinics of VA medical centers. Study population is individual responsible for guideline implementation. 242 surveys returned from 130 hospitals. CPGs were chronic obstructive pulmonary disease (COPD), diabetes, heart failure, and major depressive disorder.
Total number of interventions used were counted and type of interventions used to implement CPGs were categorized as consistently effective, variably effective, and minimally effective, based on Bero’s categories:
Consistently effective:
– Forms created/revised
– Computer interactive education
– Internet discussion groups
– Responsibilities of nonphysicians changed academic detailing

EBP Research Table Assignment

Variably effective:
– CPG workgroup
– Clinical meetings to discuss CPG

Minimally effective:
– Providers receive brief summary
– Providers receive CPG
– Providers receive pocket guide
– Storyboards
– Instructional tape of CPG
– Grand rounds

EBP Research Table Assignment
Commonly used approaches were clinical meetings to discuss guidelines (variably effective/Bero’s classification), provider receipt of brief summary (minimally effective classification), forms created or revised (consistently effective classification), responsibilities of nonphysicians revised (consistently effective classification). Most facilities used 4–7 approaches. Consistently and minimally effective approaches were used most frequently. Strategies used together almost always included one consistently effective approach.
Bradley 200460
Describe the implementation process for the Hospital Elder Life Program (HELP)—an evidence-based program for improving care of older patients.
Descriptive prospective study.
Qualitative analyses of implementation process at the beginning of implementation and every 6 months for up to 18 months.
8 hospitals implementing HELP. In-depth, open-ended interviews were conducted by telephone with physicians, nurses, volunteers, and administrative staff involved in the HELP implementation.

Major themes in implementing the HELP program were (1) gain internal support for the program, recognizing diverse requirements and goals; (2) ensure effective clinical leadership in multiple roles; (3) integrate with existing geriatric programs to foster coordination rather than competition; (4) balance program fidelity with hospital-specific circumstances; (5) document and publicize positive outcomes; (6) maintain momentum while changing practice and shifting organizational culture.
Bradley 2004177

EBP Research Table Assignment
Identify key themes about effective approaches for data feedback as well as pitfalls to avoid in using data feedback to support performance improvement efforts.
Retrospective cohort study. Evidence level 5.
Qualitative study with open-ended interviews of clinical and administrative staff at 8 hospitals representing a range of sizes, geographical regions, and beta-blocker use rate after AMI (level 9). Outcomes = key themes in use of data feedback.
8 hospitals. Interviewed physicians (n =14), nurses (n =15), quality management (n = 11), and administrative (n = 5) staff who were identified as key in improving care of patients with AMI.
Data feedback for improving performance of beta-blocker use after AMI.
7 major themes: Data must be perceived by physicians as valid to motivate change. It takes time to develop credibility of data within a hospital. The source and timeliness of the data are critical to perceived validity. Benchmarking improves the validity of the data feedback. Physician leaders can enhance the effectiveness of data feedback. Data feedback that profiles an individual physician’s practices can be effective but may be perceived as punitive. Data feedback must persist to sustain improved performance. Effectiveness of data feedback might be intertwined with the organizational context, including physician leadership and organizational culture.
Carter 200561

EBP Research Table Assignment
Evaluation of the relationship between physicians’ knowledge of hypertension guidelines and blood pressure (BP) control in their patients.
Cross-sectional study
Cross-sectional study of physicians’ knowledge about Joint National Committee (JNC) 7 hypertension guidelines (level 4).
Outcomes were BP values of patients each physician treated.
Study setting was two academic primary care clinics located in the same academic medical center. The sample was 32 primary care physicians and 613 patients they treated. Mean age of physicians was 41 years (Standard Deviation [SD]. = 10.9), majority were men (66%).
Association between physician knowledge and BP control. Covariates of presence of diabetes, patient age.
There was a strong inverse relationship between BP control rates and correct responses by physicians on the knowledge test (r = −0.524; p = .002). Strong correlation was also found between correct responses on the knowledge survey and a higher mean systolic BP (r = 0.453; p = .009). When the covariates of patient age and diabetes were added to the model, there was no longer a significant association between physician knowledge and BP control. However, the correlation (in the multivariate model) was still in the same direction; for every 5 points better on the knowledge test, there was a 16% decrease in the rate of BP control (p = .13), and for every 10 years increase in patient age, there was a 16% decrease in BP control (p = .04).
Chin 200462, 186
To determine the additive effect of additional support for organizational change techniques and chronic care management as they are added to the Health Disparities Collaborative initiatives to improve diabetes care in community health centers.
RCT
34 centers were randomized to a standardized intensity arm (Health Disparities Collaborative initiatives) or high intensity arm. (level 2).

EBP Research Table Assignment
Outcomes included process of care measures; laboratory values based on American Diabetes Association (ADA) recommendations; and patient surveys of satisfaction with provider’s communication style and overall care, attitudes about interacting with providers, knowledge of ADA recommendations, and provider performance of key processes of care (levels 1 and 2).
34 community health centers from the Midwest or West Central clusters that participated in the 1998–99 or 1999–2000 Diabetes Collaborative of the Bureau of Primary Health Care in Improving Diabetes Care Collaboratively in the Community. These centers care for the medically underserved. In the standard arm, there were 843 patients at baseline and 665 in the followup standard intensity group. 993 patients were in the high intensity arm at baseline and 818 postinterventions high intensity group. Mean age of subjects ranged from 56 to 58, a majority were female, and white.
All 34 centers were community health centers that are overseen by the Bureau of Primary Health Care and had participated in the Health Disparities Collaborative to improve diabetes care. Interventions included forming a QI team, adoption of the Plan-Do-Study-Act (PDSA) cycle for QI, learning sessions, data feedback, monthly teleconferences, and regional meetings over a year. The centers randomized to the standard intensity arm continued to receive quarterly data-feedback reports, conference calls with other centers, and a yearly in-person meeting with other health centers. The high intensity sites received the standard intensity interventions plus additional support in organizational change strategies, chronic care management, and strategies to engage patients in behavioral change designed to get them to be more active in their care.
Centers in the high intensity arm showed higher rates of Hgb A1c and urine microalbumin assessment, eye exam, foot exam, dental referral, and increased prescription of home glucose monitoring postintervention as compared to the standard intensity arm. No significant differences by treatment arm were noted for patient survey data.
Davey 2005187
To estimate the effectiveness of persuasive interventions, restrictive interventions, and structural interventions (alone or in combination) in promoting prudent antibiotic prescribing to hospital inpatients.
Systematic literature review. Evidence level 1. (Table 3.1)
RCTs, quasi-randomized controlled trials, controlled before and after studies, and interrupted time series studies (levels 2 and 3).

EBP Research Table Assignment
Outcomes were appropriate antibiotic prescribing and patient outcomes, including length of stay, inpatient mortality, and 28-day mortality (levels 1 and 2).
66 studies (43 interrupted time series studies, 13 RCTs, 6 controlled before/after studies, 2 controlled clinical trials, 1 cluster clinical trial, 1 cluster randomized trial. The majority of studies (42) were from the United States. Study participants were health care professionals who prescribe antibiotics to hospitalized inpatients receiving acute care.
Interventions were categorized as persuasive interventions (distribution of educational materials; local consensus process; educational outreach visits; local opinion leaders; reminders provided verbally, on paper, or via the computer; audit and feedback), restrictive interventions (formulary restrictions, prior authorization requirements, therapeutic substations, automatic stop orders and antibiotic policy changes), and structural (changing from paper to computerized records, introduction of quality monitoring mechanisms).
A wide variety of interventions has been shown to be effective in changing antibiotic prescribing for hospitalized patients. Restrictive interventions have a greater immediate impact than persuasive interventions, although their impact on clinical outcomes and long-term effects are uncertain.
Estabrooks 200420
To map research utilization as a field of study in nursing and identify the structure of this scientific community, including the current network of researchers.
Systematic literature review.

EBP Research Table Assignment
Bibliometric analysis to map the development and structure of the field.

Outcomes were journal patterns of publication, country patterns of publication, author patterns of publication, references per article, co-occurrence of words, citation patterns, interdisciplinary flow of information, within field diffusion of information.
630 articles (350 opinion articles, 65 conceptual articles, 112 research utilization studies, 103 research articles) published in 194 different journals.
Article location and data abstraction up to 2001/2002.
On the basis of co-citation, scholars at the core of the field are Horsley, Stetler, Fun, Titler, and Goode. The field has attained a critical mass of nurse scholars and scholarly works as demonstrated by more than 60% of the references in articles are to research by nurses. Emergence of interdisciplinary collaborative groups in this field is yet evolving.
Feldman 200564

Murtaugh 200577
Tested a basic and an augmented e-mail reminder to improve evidence-based care of individuals with heart failure (HF) in home health care settings.
RCT.
Evidence level 2 (Table 3.1)
Prospective randomized trail with 3 groups (control, basic e-mail reminder, augmented e-mail reminder). Outcome measures were nursing practices and patient outcomes.
Level 1 outcomes.

EBP Research Table Assignment
Older adults with heart failure (n = 628; x̄ age = 72) and nurses (n = 354; x̄ age = 43.6; 93% female) caring for those patients.
Home health care agency in a large urban setting.
Basic e-mail reminder upon patient admission to the nurses’ care that highlighted 6 HF-specific clinical practices for improving patient outcomes. Augmented intervention included basic e-mail reminder plus package of material for care of HF patient (medication management, prompter card for improving communication with physicians, self-care guide for patients) and followup outreach by a clinical nurse specialist (CNS) who served as an expert peer.
Basic and augmented intervention significantly improved delivery of evidence-based care over control group; augmented intervention improved care more than basic intervention.
Foxcroft and Cole 2000188
Organizational infrastructures to promote evidence-based nursing practice.
Systematic literature review.
RCT, controlled clinical trial, and interrupted time series (levels 2, 3, 7). Unit of intervention was organizational, comprising nurses or groups of professionals including nurses.
Outcomes = objective measures of evidence-based practice (levels 1 and 2).
121 papers were identified as potentially relevant, but no studies met the inclusion criteria. After relaxing the criteria, 7 studies were included and all used a retrospective case study design (15).
Entire or identified component of an organizational infrastructure to promote effective nursing interventions.
No high-quality studies that reported the effectiveness of organizational infrastructure interventions to promote evidence-based nursing practice were identified.
Conceptual models that were assessed positively against criteria are briefly included in this review.
Greenhalgh 200522
Diffusion, spread, and sustainability of innovations in the organization and delivery of health services.
Systematic literature review. Evidence level 1 (Table 3.1).
Metanarrative review.

EBP Research Table Assignment
Comprehensive report of factors and strategies to promote use of innovations in health care services.
7 key topic areas addressed: characteristics of the innovation, adoption by individuals, assimilation by organizations, diffusion and dissemination, the inner context, the outer context, implementation and routinization.
Complex process requiring multiple strategies.
Excellent resource of scholarly work in knowledge transfer and innovation adoption.
Grilli 2002120
Assess the effect of mass media on use of health services.
Systematic literature review. Evidence level 1 (Table 3.1).
RCTs, controlled clinical trials, controlled before-and-after studies, and interrupted time series analysis (levels 2, 3, 4).
Outcomes were objective measures of health services (drugs, medical or surgical procedures, diagnostic tests) by professionals, patients, or the public.
26 papers reporting 20 time series and on controlled before-and-after study met the inclusion criteria.
All studies relied on a variety of media, including radio, TV, newspapers, posters, and leaflets. To meet inclusion criteria, studies had to use mass media, be targeted at the population level, and aimed to promote/discourage use of evidence-based health care interventions or change public lifestyle.
Mass media campaigns have a positive influence upon the manner in which health services are used. Mass media have an important role in influencing use of health care interventions. Mass media campaign is one of the tools that may encourage use of effective services and discourage those of unproven effectiveness.
Grimshaw 2004144

EBP Research Table Assignment

Grimshaw 200665
Assessment of the effectiveness of guideline dissemination and implementation strategies.
Systematic literature review. Evidence level 1 (Table 3.1).
RCTs, controlled clinical trials, controlled before-and-after studies, interrupted time series from 1966 to 1998 (levels 2, 3, 4).
Outcomes were objective measures of provider behavior and/or patient outcomes (levels 1, 2).
Studies of guidelines aimed at medically qualified professionals. (Studies on guidelines aimed at multiple professionals were included only if results for medical professionals were reported separately or if medical professionals represented more than 50% of the targeted population.) The review included 110 clustered RCTs, 29 patient RCTs, 7 clustered controlled clinical trials, 10 patient controlled clinical trials, 40 controlled before-and-after studies, and 39 interrupted time series designs. The most common setting was primary care (39%) followed by inpatient settings (19%) and generalist ambulatory settings (19%). Other studies addressed settings across sites of care or were in a variety of other types of settings (e.g., nursing homes).
Interventions were educational materials, educational meetings, educational outreach, consensus, opinion leaders, patient-directed interventions, audit and feedback, reminders, other professional (marketing, mass media), financial interventions, organizational interventions, structural interventions, and regulatory interventions. Studies compared single interventions to no intervention, multifaceted interventions to no intervention, or a control receiving one or more single intervention. This systematic review compared findings from studies with a single intervention against a “no-intervention” control group; single interventions against an “intervention” control group; multifaceted interventions against “no-intervention” control group (7 different types of comparisons); multifaceted interventions against intervention controls (4 different types of comparisons). A total of 309 comparisons were done. This systematic review also includes economic evaluations and cost analysis.
This is a comprehensive review of implementation strategies. The reader is referred to the technology report, as a comprehensive summary of findings is beyond the scope of this chapter. Overall findings include: the overall quality of studies were poor; the majority of comparisons (86.6%) observed improvements in care; reminders are a potentially effective intervention and are likely to result in moderate improvements in care processes; educational outreach may result in modest improvements in processes of care; educational materials and audit and feedback appeared to result in modest improvements in care; multifaceted interventions did not appear to be more effective than single interventions; multifaceted interventions did not appear to increase with the number of component interventions. The lack of a coherent theoretical basis for understanding professional and organizational behavior change limits the understanding of the findings from studies.
Grimshaw 2006124

EBP Research Table Assignment
Examine the feasibility of identifying opinion leaders using a sociometric instrument (frequency of nomination of an individual as an OL by the responder) and a self-designating instrument (tendency for others to regard them as influential).
Cross-sectional study. Evidence level 5 (Table 3.1).
Survey. Mailed questionnaires of different professional groups.
Outcomes = general and condition-specific opinion leader types classified as sociometric OLs and self-designated OLs (level 2 outcomes).
All general practitioners, practice nurses, and practice managers in two regions of Scotland. All physicians and surgeons and medical and surgical nursing staff in two district general hospitals and one teaching hospital in Scotland as well as Scottish obstetric and gynecology, and oncology consultants.
None
The self-designating instrument identified more OLs. OLs appear to be condition specific.
Horbar 200466
To evaluate a coordinated, multifaceted implementation intervention designed to promote evidence-based surfactant therapy.
Clustered randomized trial.
Cluster randomized trial with randomization at the hospital level (level 2). Outcomes were proportion of infants receiving their first dose of surfactant in the delivery room, proportion of infants treated with surfactant who received their fist dose more than 2 hours after birth, and time after birth at which the first dose of surfactant was administered; proportion of all infants who developed a pneumothorax, and proportion of all infants who died prior to discharge (levels 1 and 2).

EBP Research Table Assignment
114 hospitals with membership in the Vermont Oxford Network, not participating in a formal quality improvement collaborative, with the majority of infants born in the hospital rather than transferred in and born in 1998 and 1999; received the first dose of surfactant within 15 minutes after birth. Subjects were high-risk preterm infants 23 to 29 weeks gestational age. The intervention group had 3,313 neonates and 2,726 in the comparison group.
The multifaceted 18-month intervention included quarterly audit and feedback of data, evidence reviews, an interactive 3-day training workshop, and ongoing support to participants via conference calls and e-mail discussion.
The proportion of infants 23 to 29 weeks gestational age receiving surfactant in the delivery room was significantly higher in the intervention than the control group for all infants (OR = 5.38). Those who received surfactant more than 2 hours after birth was significantly lower in the intervention than control group (OR = 0.35). There were no significant differences in rates of mortality or pneumothorax between groups. Infants in the intervention group received their first dose of surfactant significantly sooner after birth with a median time of 21 minutes as compared to 78 minutes in the control group (p< .001).
Hysong 200667
Exploratory study of how high-performing facilities and low-performing facilities differ in the way they use clinical data for feedback purposes.
Cross-sectional study.
Descriptive, qualitative, cross-sectional study. Subjects were interviewed using a semistructured interview format (level 4). Outcomes were participant responses to questions asking how CPGs were currently implemented at their facility, including strategies, barriers, and facilitators.
Study setting was 6 VA medical settings (from a pool of 15) ranked as high performing (n = 3) and low performing (n =3) organizations with respect to 20 indicators for 6 chronic conditions treated in outpatient settings. 102 employees across 6 facilities were the subjects. Within each facility, facility leadership (n =25), middle management (n = 34), and outpatient clinic personnel (n =33) were interviewed.
No study intervention, but transcripts were analyzed using grounded theory, and passages that specifically addressed feedback of data were included in the analyses.
High-performing institutions provided timely, individualized, nonpunitive feedback to providers, whereas low performers were more variable in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports. The concept of actionable feedback emerged as the core concept around which timeliness, individualization, nonpunitiveness, and customizability are important.
Irwin & Ozer 200468

EBP Research Table Assignment

Ozer 2005189
To determine if a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients compared to usual care.
Controlled trial.
2 intervention outpatient pediatric clinics and 2 comparison outpatient pediatric clinics in the same health system were used to test the intervention. Level 3. Outcomes were adolescent reports of whether their provider screened and counseled them for risky behavior (tobacco, alcohol, drugs, sexual behavior, and safety—helmet and seatbelt use). Level 2.
4 outpatient pediatric clinics within Kaiser Permanente, Northern California. 76 clinicians were in the study (37 in each treatment arm). Adolescent reports of provider behavior—across all phases of the study, the intervention sample size was 1,717, and the comparison sample size was 911. Mean age of adolescents was 14.8 years (SD = 1.34). Data were collected from adolescents at baseline, following training, and following forms implementation.
The intervention was 2 phases. First phase was an 8-hour clinician training in adolescent preventative services based on social cognitive theory, including didactic education, discussions, demonstration role plays, and interactive role-plays at each intervention site (4 months). Second phase was implementation of screening and chart forms customized for this study (4 months). All clinicians participated in the training and the tools were implemented on a clinic-wide basis. Local opinion leaders were integrally involved in the intervention.
Average baseline screening rates in the intervention group ranged from 42% for helmet use to 71% for tobacco use. Following training, screening rates increased significantly across all 6 target areas, ranging from 70% for helmet use to 85% for tobacco use, and remained constant during the posttools implementation phase. Counseling rates followed a similar pattern. By comparison, screening and counseling rates in the comparison group tended to remain stable across all 3 data collection points. Screening and counseling rates were significantly higher in the intervention group than the comparison group after the full implementation of the intervention; screening and counseling rates were significantly higher in the intervention than the comparison group after the training component of the intervention; screening and counseling rates in the comparison group tended to remain stable across all 3 data collection points. Screening and counseling rates were significantly higher in the intervention group than the comparison group after the full implementation of the intervention; screening and counseling rates were significantly higher in the intervention than the comparison group after the training component of the intervention; screening and counseling rates did not increase significantly in the intervention group compared to the comparison group after the addition of the tools component.
Jacobson 200569
Assessment of the effectiveness of patient reminder and patient recall systems in improving immunization rates.
Systematic literature review. Evidence level 1 (Table 3.1).
RCTs, controlled before-and-after studies, and interrupted time series (levels 2 and 3).
Outcomes were immunization rates or the proportion of the target population up to date on recommended immunizations.

EBP Research Table Assignment
43 studies. Approximately three-fourths of the studies were conducted in the United States. The majority of the studies were RCTs. Studies included children and adults and a variety of settings.
Reminder methods and recall systems included letters to patients, postcards, person-to-person telephone calls, autodialer, postcard and phone combination, and tracking and outreach.
Patients receiving patient reminder and recall interventions were more likely to have been immunized or up to date on immunizations (OR = 1.70). All types of reminders and recall were found to be effective, with increases in immunization rates on the order of 5%– 20%. Person-to-person telephone reminders were the most effective single approach (OR = 1.92). Letter reminders were similar to phone reminders in effectiveness (OR = 1.89). Reminder and recall interventions were effective for children and adults in all types of settings.
Jamtvedt 200670
Use of audit and feedback to improve professional practice.
Systematic literature review. Metaregression along with visual and qualitative analyses.
Evidence level 1 (Table 3.1).
Randomized trails (level 2). Outcome measures = noncompliance with guideline recommendations (level 2).
85 studies. 53 trials in North America, 16 in Europe, 8 in Australia, 2 in Thailand, 1 in Uganda. In most trials, the professionals were physicians; in 2 studies the providers were nurses, and 5 involved mixed providers.
Audit and feedback defined as any summary of clinical performance of health care over a specified period of time, delivered in written, electronic, or verbal format.
Audit and feedback can be effective in improving professional practice with effects generally moderate. Absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low. Audit and feedback should be targeted where it is likely to effect change.
Jones 200471

EBP Research Table Assignment
Improvement of pain practices in nursing homes.
Clustered RCT. Evidence level 2 (Table 3.1).
An intervention study to improve pain practices (RCT). The intervention was implemented in 6 nursing homes (level 2). Outcomes = pain knowledge and attitudes of staff; pain assessment and treatment decisions based on 2 short case studies; barriers to effective pain management. Outcomes measured from questionnaires distributed to nurses and nursing assistants (level 3).
12 long-term care sites in Colorado—6 in urban sites and 6 in rural sites. Nursing homes ranged in size from 65 to 150 beds.
Education for staff; resident educational video; designation of a 3-member internal pain team; pain vital sign; site visits with discussion of feedback reports; pain rounds and consultations. Implementation phase lasted 9 months.
No significant treatment effect for staff knowledge or staff attitudes; staff in the treatment group were 2.5 times more likely to chose an aggressive pain management strategy than those in the control group (p = .002); no significant treatment effect for decreasing barriers to pain management.
Katz 200472,98
Testing an intervention to improve use of EBP smoking cessation guidelines.
RCT with randomization at the clinic level. Evidence level 2 (Table 3.1).
Prospective randomized trial of 8 primary care clinics in southern Wisconsin (level 2). Outcomes included staff performance and patient quit rates (levels 1 and 2).
8 community-based clinics (6 family practice, 2 internal medicine).
Multimodality intervention (5 components—didactic and interactive education of staff, modified vital signs stamp imprinted on each encounter form, offering nicotine patches and telephone counseling, group and confidential individual feedback to providers on whether clinicians had assessed smoking status and provided cessation counseling as needed) to implement AHRQ smoking cessation guideline.
Quit rates higher in experimental (E) sites at 2 and 6 months. Percentage of patients advised to quit smoking higher at E sites than control (C) sites.
Levine 200473
Test a nurse-administered, protocol-driven model for comprehensive preventive services in a low-income outpatient setting. Focus was on preventive services as recommended by the U.S. Preventive Services Task Force (USPSTF).
Controlled trial.
Controlled comparison using a convenience sample of patients within a single practice (n = 987) and a usual care group (n = 666) obtained from a random sample of households from the postal zip codes served by the same practice (level 3). Outcomes were percentage of preventive services initiated in the treatment arm versus the comparison arm (level 1).
Primary care single practice with internal medicine, family medicine, and pediatric clinics. Patients receiving care in this clinic between January and September 2001. Children = 514 (about 170 in each of 3 age groups: 0–2, 3–7, 8–17; 63% African American). Adults = 473 (about 170 in each age group 18–49 and 50–64; 130 in 65 or older; 76% African American).
Offer all identified preventive services that are needed using a nursing model under the guidance of a protocol agreed upon by the medical staff.
Use of a nursing protocol for USPSTF recommendations was associated with a significantly higher percentage of preventive services initiated (99.6%) in the experimental arm as compared to usual care group (18.6%) (p < .001).
Locock 2001123
Role of opinion leader in innovation and change.
Systematic literature review.
Case studies using principally qualitative methods.
Outcomes = effectiveness of opinion leaders in promoting change/adoption of evidence-based practices (level 2.)
Variety of acute care and primary care settings. Evaluation of PACE project100 and Welsh Clinical National Demonstration Project.
Local opinion leaders defined as those perceived as having particular influence on the beliefs and actions of their colleagues, either positive or negative.
Both expert and peer opinion leaders have important and distinct roles to play in promoting adoption of EBPs. Opinion leadership is part of a wider process that cannot be understood in isolation of other contextual variables with which it may interact. The value of the expert opinion leader is in the initial stages of getting an idea rolling, endorsing the evidence, and translating it into a form that is acceptable to practitioners and takes account of their local experience. Peer opinion leader influence seems to be important in mainstream implementation, providing a role model for fellow practitioners and building their confidence. The local context may modify or magnify the opinion leader influence.
Loeb 200474
To test the effect of a multifaceted implementation intervention for safely reducing antimicrobial prescriptions for suspected urinary tract infections in nursing home residents.
Cluster RCT.
The study design was randomization of 24 nursing homes to an intervention group or a usual care group (level 2). Main outcome measures were antimicrobials prescribed for urinary infections, total antimicrobials, hospitalizations, and deaths (level 1).
Free standing, community-based nursing homes with 100 or more beds in Hamilton, Ontario, region and Boise, Idaho, region were sites for the study. The numbers of residents were 2,156 in the intervention arm and 2,061 in the comparison arm.
Implementation of algorithms for diagnostic testing and antibiotic prescribing developed from research findings. Implementation strategies included interactive education with nurses, one-on-one meeting with physicians that see more than 80% of the patients, written materials, real-time paper reminders, and quarterly outreach visits targeted to nurses and physicians.
The rate of antimicrobial use for suspected urinary infections was significantly lower in the treatment arm (1.17 courses of antimicrobials per 1,000 resident days) as compared to the comparison arm (1.59 per 1,000 patient days) (P = .03). The proportion of antimicrobials prescribed for suspected urinary infections were lower in the intervention arm than the comparison arm (P = .02). There was no significant difference for total antimicrobial use, rate of urine cultures obtained, overall hospitalization, or mortality.
Lozano 2004174
To test the effectiveness of 2 implementation interventions in reducing asthma symptom days as compared to usual care.
Cluster RCT.
RTC. Outcomes were annualized asthma symptom days, asthma-specific functional health status, and frequency of brief oral steroid bursts (level 1).
42 primary care practices in 3 locales and targeted 3–17-year-old children with mild to moderate persistent asthma enrolled in practices affiliated with managed care organizations. Among the 638 patient subjects, the mean age was 9.4 years (SD = 3.5); the majority were white (66%) and boys (60%).
3 treatment arms were usual care, provider (MD, PA, NP) oriented strategy of targeted education through an on-site peer leader, and an organizational approach that combined the provider education with a nurse-run intervention (planned care arm) to better organize chronic asthma care in the primary care practice.
Children in the planned care arm had 13.3 fewer symptoms annually (P =.02) and 39% lower oral steroid burst rate per year relative to usual care (P =.01). Those in the peer leader arm showed a 36% decrease in annualized steroid bursts per year as compared to usual care (P = .008). Improvements in asthma-specific functional status were also found for both the peer leader and planned care arm as compared to usual care.
McDonald 200575
Testing of 2 computer-based reminder interventions designed to promote evidence-based pain management practices among home care nurses.
RCT. Evidence level 2 (Table 3.1).
Nurses were randomly assigned to one of 3 treatment groups (control, basic e-mail reminder, augmented e-mail reminder). Outcomes = pain management practices of nurses and patient’s pain (levels 1 and 2).
Home health care. Nurses were mostly female (> 90%) with an average age of 43.3 years.
Basic e-mail reminder that focused on 6 key practices (2 treatment arms) was sent to nurse every time an eligible cancer patient with pain was admitted to his/her care. Nurses in the augmented intervention group also received provider prompts, patient education material, and CNS outreach.
Nursing pain management practices did not differ significantly among the groups (P < .05), but pain levels were lower in the 2 treatment groups as compared to the control group. Patients treated by nurses in the augmented group had a 25% reduction in the probability of hospitalization.
O’Brien 1997119
Assess the effect of outreach visits on improving professional practice or patient outcomes.
Systematic literature review. Evidence level 1 (Table 3.1).
Randomized trials (level 2). Outcomes of provider performance (level 2).
18 trials. Providers were mainly primary care physicians practicing in community settings. In 13 trials the behaviors were prescribing practices. 10 trials in North America, 4 in Europe, 2 in Indonesia, and 2 in Australia.
Outreach visits defined as use of a trained person who meets with providers in their practice settings to provide information with the intent of changing provider’s performance. The information may include feedback about performance.
Positive effects on practice were observed in all studies. Only 1 study measured a patient outcome. Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behavior, especially prescribing. Further research is needed to identify key characteristics of outreach visits important to success.
O’Brien 1999116
Assessment of the use of local opinion leaders on the practice of health professionals or patient outcomes.
Systematic literature review. Evidence level 1 (Table 3.1).
RCTs (level 2). Outcomes were objectively measured provider performance in a health care setting or health outcomes (levels 1 and 2).
Focus was on health care providers responsible for patient care.
Use of providers nominated by their colleagues as educationally influential. 8 studies met inclusion criteria. A variety of patient problems were targeted.
In 3 trials that measured patient outcomes, 1 achieved an impact on practice. Only 2 trials provided strong evidence for improving performance of health care providers. Local opinion leaders may be important change agents for some problems.
O’Brien 2001118
Assess the effects of educational meetings on professional practice and health care outcomes.
Systematic literature review. Evidence level 1 (Table 3.1).
Randomized trials and well-designed quasi-experimental studies (levels 2 and 3). Outcomes were objectively measured health professional practice behaviors or patient outcomes in a setting where health care was provided (levels 1, 2, 3).
32 studies met inclusion criteria with 30 RCTs. 24 studies were in North America, 2 in the United Kingdom, and 1 each in Australia, Brazil, France, Indonesia, Sri Lanka, and Zambia. Most of the study participants were physicians; 4 included nurses, and 3 other health professionals.
The intervention was defined as continuing education: meetings, conferences, lectures, workshops, seminars, symposia, and courses that occurred off-site from the practice setting. Education was defined as didactic (predominately lectures with Q and A), or interactive (sessions that involved some type of interaction in small, moderate, or large groups). 7 studies were didactic and 25 were interactive. Duration and frequency of the intervention varied widely.
The few studies that compared didactic education to no intervention did not show an effect on professional practice. Studies that used interactive education were more likely to be effective in improving practice. Studies did not include information to determine what makes some interactive educational sessions more effective than others. Interactive workshops can result in moderately large changes in professional practice. Didactic education alone is unlikely to change professional practice.
Redfern 200379
Evaluation of the South Thames Evidence-based Practice (STEP) project.
Pretest and posttest.
Each of the 9 projects followed a pretest/posttest design within a clinical audit framework over a period of 27 months (level 6). Outcomes = intermediate outcomes of uptake of change by staff and patient outcomes (levels 1 and 2).
9 projects that focused on improving evidence-based nursing practices. UK sites included acute care wards, community nursing services, and long-term care. Topics were leg ulcer management, breast-feeding, pressure ulcer care, nutrition in stroke patients (n = 2), Use of functional independence measure (FIM) assessment tool, assessment of continence, assessment and transfer of older adults on discharge from hospital, family therapy in schizophrenia.
A 2-week training program followed by 3 monthly seminars, staff training program, active support in the practice setting.
Intermediate outcomes improved in most projects; leaders’ ratings of staff adherence were moderate or better in the majority of the projects; patient outcomes improved in most projects. Organizational factors were found to have a major impact on achieving successful change in practice. Having enough staff of the right skill mix, strong leadership, supportive managers and colleagues, and organizational stability are important to successful change. Project leaders and a credible change agent who works with practitioners face-to-face to encourage enthusiastic involvement are also important.
Shaw 2005185
Tailored interventions to address specific identified barriers to change in professional performance.
Systematic literature review with metaregression. Evidence level 1 (Table 3.1).
RCTs (level 2). Outcomes = professional performance, patient outcomes, or both (levels 1 and 2).
15 RCTs. 7 in primary care or community settings and health care professionals responsible for patient care. 10 in North America, 2 in the United Kingdom, 2 in Indonesia, and 1 in Norway.
An intervention was defined as tailored if it was chosen after identification of barriers and to overcome those barriers.
Results were mixed with variation in the direction and size of effect. The effectiveness of tailored interventions remains uncertain, and more rigorous trials including process evaluations are needed.
Titler 200681
Testing a TRIP intervention for promoting adoption of evidence-based acute pain management practices for care of older adults hospitalized with hip fracture.
RCT with randomization at the clinic level. Evidence level 2 (Table 3.1).
Prospective randomized trial of 12 acute care hospitals in the Midwest United States (level 2). Outcomes included nurse and physician performance, patient pain levels, and cost effectiveness (levels 1 and 2).
12 large (n = 2), medium (n = 6), and small hospitals (n = 4) in the Midwest.
Multifaceted intervention that addressed the characteristics of the EBP, the users, the social context of care, and communication, based on Rogers’ diffusion of innovation framework.
Acute pain management strategies improved more in the experimental than comparison group, and the TRIP intervention saved health care dollars.
Wensing 200682
Organizational strategies for improving professional performance, patient outcomes, and costs.
Systematic literature review. Evidence level 1.
A review of reviews that included RCTs, interrupted time series, controlled before/after studies, and prospective comparative observational studies (levels 2, 5, 6, 7). Outcomes = professional practice and patient outcomes (levels 1 and 2).
36 reviews were included. A taxonomy of organizational strategies to improve patient care was developed to organize findings.
Revision of professional roles, multidisciplinary teams, integrated care services, knowledge management, quality management.
Revision of professional roles can improve professional performance, while positive effects on patient outcomes remain uncertain. Multidisciplinary teams can improve patient outcomes but have primarily been tested in highly prevalent chronic diseases. Integrated care systems can improve patient outcomes and save costs; they have been extensively tested in highly prevalent chronic conditions. Professional performance and patient outcomes can be improved by implementation of computers in clinical practice settings (knowledge management). Effects of quality management on professional performance and patient outcomes remain uncertain. There is growing evidence of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited; for no strategy can the effects be predicted with high certainty.
Zwarenstein 2000117
Usefulness of interprofessional education (IPE) interventions on professional practice and health care outcomes.
Systematic literature review. Evidence level 1 (Table 3.1).
RCTs, controlled before-and-after studies, and interrupted time series studies (levels 2, 6, 7). Outcomes included health care outcomes (mortality rates, complication rates, readmission rates) and impact on professional practice (teamwork and cooperative practice) (levels 1 and 2).
89 studies were reviewed for possible inclusion, but none met the inclusion criteria.
An educational intervention during which members of more than one health and/or social care profession learn interactively together for the purpose of improving collaborative practice and/or the health of patients.
Despite finding a large body of literature on the evaluation of IPE, studies lacked the methodological rigor needed to understand the impact of IPE.
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Study design type: Use the following numbers for categories to reference the specific type of evidence (“evidence level”):

Meta-analysis
Randomized controlled trials
Non-randomized trials
Cross-sectional studies
Case control studies
Pretest and post-test (before and after) studies
Time series studies
Noncomparative studies
Retrospective cohort studies
Prospective cohort studies
Systematic literature reviews
Literature reviews, nonsystematic/narrative
Quality improvement projects/research
Changing practice projects/research
Case series
Consensus reports
Published guidelines
Unpublished research, reviews, etc.

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