This article will explore the evidence for educational intervention in any area of clinical practice. An initial review of the relevant evidence on the interventions designed to change professional behaviour will be followed by a brief description of two randomised-controlled trials. The first is an education outreach intervention done in 75 general practice and the second a more intensive educational intervention conducted in eight general practices in the United Kingdom. The article will conclude by making specific recommendations on the education of primary care professionals in mental health. These recommendations will be based on our current knowledge of the published evidence and the author's experience and understanding of mental health and primary care both in high and low income countries.
Review of educational intervention that change professional behaviour
Research on educational strategies designed to change professional behaviour is limited to North America and the Europe (Effectiveness Health Care 1999). This section will provide a summary of the research on the effectiveness of some of the most commonly used educational interventions. These are as follows:
a) Passive dissemination of educational material: The use of blanket strategies such as passive dissemination of educational material in the form of information leaflets, educational booklets or other such printed material on their own does not lead to a changes in professionals' clinical practice (Freemantle, 1999, Lomas, 1991). Such methods of dissemination of educational material are more likely to be effective if they are supported by active educational re-inforcements and if the implementation is supported by patient-specific reminders (Effective Health Care, 1994).
b) Educational outreach interventions: Research on more specific interventions, however, is more promising. A review of 18 studies on the effects of educational outreach visits on changing clinical practice was described as promising (Thomson, 1999). The details of the educational outreach intervention will be discussed in further detail in this next part of this chapter.
c) Local opinion leaders: There is anecdotal evidence in the UK that there was a sharp drop in people requesting antidepressants in primary care, following the adverse comments made by the late Lady Diana in the UK on the use of antidepressants for the treatment of depression. This is an example of the powerful effect of an opinion leader on clinical behaviour. In most instances, however, local opinion leaders are seldom of celebrity status and are mostly people of local stature such as a hospital consultant, a university academic or even government health- policy officials. The effects of information conveyed by such individuals to health professionals have been previously evaluated. Data from a review of eight studies reported a mixed effect on clinical practice (Thomson, 1999). Hence much more research is needed on the effectiveness of the intervention, before supporting its widespread implementation.
d) Audit and feedback: is a process that involves the collection of practice specific information on various areas of clinical performance that is fed back to the relevant health professionals, with specific suggestions on how their practice can be enhanced. Much of the research in this field has focussed on prescribing and the ordering of diagnostic tests. A review of studies that compared audit and feedback to no intervention (Thompson, 1999) identified 13 studies, eight of which produced a statistically significant effect in favour of the intervention. These observed effects, however, were only mild to moderate.
e) Computerised reminders: providing prompts on evidence based clinical practice are effective means of educating doctors on appropriate management. The use of such computer reminders are limited to settings where the clinical records are computerised. A review of 68 studies suggested that computer based decision support systems lead to improved decision making on drug dosing, the provision of preventative care and the clinical management of people in general practice. There is, however, no evidence that such reminders enhance the process of clinical diagnosis ( Hunt, 1998).
f) Change Management: can occur within a practice through changes in the organisational structure. Continuous Quality Improvement (CQI), a form of change management has been extensively investigated. Of the many studies identified, 41 used an uncontrolled before and after design, 12 used a cross sectional design and 3 used a randomised controlled trial design. The results from the uncontrolled and cross sectional design favours CQI, whereas none of the three RCTs report any such positive effects (Shortell, 1998). Hence the value of such interventions still remain unproven. This is a good example where the type of evaluation must be considered when assessing the effectiveness of the intervention.
A randomised trial of Evidence based Outreach (EBOR) - a multi-centre UK study
This part of the article will now describe a study conducted by the author in collaboration with academics from three universities in the United Kingdom (Freemantle, 2002). The Department of Health of the United Kingdom funded the study. The Evidence based outreach trial was designed to examine the acceptability and effectiveness of outreach visits using a range of evidence based clinical practice guidelines to promote changes in prescribing practices in primary care. The study also aimed to examine the importance of several practice factors on the effectiveness of the intervention.
a) The study participants: were general practitioners that were randomly selected from lists provided by the 12 participating United Kingdom National Health Service health authorities. Health authorities have an average population of around 250, 000 and cover a defined geographic area. Around 95% of the general population are registered with a general practitioner. All practices were potentially eligible for the study as long as they were willing to take part.
b) Intervention: Four clinical practice guidelines were developed using established techniques by the North of England Guidelines Development Project (North of England Guidelines). These were, the use of aspirin as antiplatelet therapy, the use of angiotensin converting enzyme (ACE) inhibitors in heart failure, the use of non steroidal anti-inflammatory drugs (NSAID) in the treatment of pain thought to be due to osteoarthritis and the choice of antidepressants in the treatment of depression. Community pharmacists were recruited to the study on a locum basis and undertook a three day training and orientation programme that focussed on the content of the guidelines and social marketing strategies. The community pharmacist intervention involved two visits for each guideline topic. Each practice was offered outreach visits on two of the four topics according to a predetermined randomisation schedule. The content of the educational visit was dependent upon the educational need of the practice and followed the model of educational outreach visits developed by Avorn and Soumerai (Avorn & Soumerai, 1983) (Box 1). The pharmacist were provided with copies of the guidelines, summary sheets describing the main recommendations on a single sheet of paper and key clinical papers. They were also provided with promotional material such as mugs, pens and sticky "post it" notepads with key messages from each guideline printed on them. The community pharmacists aimed to include all members of the practice in-group visits, although the visits did go ahead if some members were missing.
c) Recruitment and training of community pharmacists: The pharmacists were recruited by mailing all the community pharmacists in each Health Authority and through an advertisement in a national pharmaceutical journal. The pharmacist was appointed in each health authority to work on a locum basis. The training of the pharmacists was achieved over two courses. The first comprised a two-day residential course covering the content of the guidelines and the methods and process of delivering each component of the intervention. The second course re-inforced these topics and focussed strongly on communication skills. Good communication was an essential pre-requisite for this intervention and was hence covered both theoretically and through role-play of a range of common clinical and organisational scenarios. Throughout the study period, an academic pharmacist who fielded any queries that arose from their contacts with the general practitioners supported the community pharmacists.
d) Outcome measures: were derived from each guideline on the basis that they reflected important aspects of the recommendations. All NHS prescriptions are returned to the Prescription Pricing Authority (PPA) once a pharmacist has dispensed them. The pre-intervention period sampling frame of eligible patients was identified from copies of all relevant prescriptions collected by the patients that were prescribed for one month before the intervention was delivered. A similar post intervention sample for the same month a year later was identified from prescriptions selected on the same basis. Thus a two-stage process was used in which the PPA provided photocopies of the prescriptions collected by the patients from targeted practices for specific indications relevant to the guideline topics and the time periods. These data provided the basis of a sampling frame that linked target prescriptions with patients' names that was then used to locate relevant notes within the study practices. Within each practice, patients who met the inclusion criteria were identified and random samples of 25 patients for the pre-intervention and post intervention periods were selected. The proportion of patients treated in line with recommendations was established from the clinical records (both computerised and paper based) for each guideline for both the pre and post intervention periods. Data was collected in a standardised manner by two trained researchers. Hence the outcomes were: for aspirin, the proportion of people receiving nitrates for angina and were also receiving low dose aspirin; for ACEI, the proportion of people on loop diuretics that were identified with heart failure and were also taking ACEI; for antidepressants, the proportion of those on antidepressant therapy that were routinely prescribed tricyclic antidepressants as a first line treatment and for NSAID, the routine adherence to a sequence of analgesia starting ibuprofen as a first line before considering diclofenac or naproxen.
e) Results: Overall 107 practices were approached across 12 participating health authorities and 75(70%) initially agreed to take part (figure 1). Data on 11, 328 patients was collected representing the work of 162 GPs and 69 practices. Overall the outreach had a significant effect upon practice (table 1). Practices with two or fewer practitioners showed a substantial reaction to the intervention. In contrast the effect in larger practices was modest and statistically non-significant (table 1). This is due to various reasons. First in small practices staff may be more amenable to the decision to adopt different working practices while in larger ones working practices may have greater organisational complexity and may be much harder to influence. Secondly the intervention may be more intensive in smaller practices because of the nature of group educational interventions. Not all practitioners were present at every meeting or available for follow up visits in larger practices while in single handed practices the visits could only proceed if the doctor was present. In the small practice 96% of the doctors were present at all meetings with the community pharmacists as compared with 48% in the larger practices. The extent to which participation in meetings affected uptake of guideline messages was examined directly in the generalised linear model. In tow separate analyses, those practices in which 75% or more practitioners were present at the meeting did not differ in response from those who had a lower level of attendance. Similarly, in those practices in which 60% or more doctors attended meetings no difference was found. Thus the difference in effect may not be simply explained through a dilution effect from reduced attendance in larger practices.
f) When is it cost-effective to change the behaviour of health professionals: In the main analysis, the cost effectiveness messages (e.g. Aspirin and ACEI) was worth implementing but the cost-saving message (antidepressant treatment) was not (Mason et al, 2001). Changing the choice of antidepressant for depression achieves small cost savings that do not exceed the cost of its implementation method. The promotion of interventions to reduce mortality or major morbidity, such as the improved management of heart failure by using angiotensin C inhibitors drugs in preference to other therapies, is more likely to prove attractive than a switch from more expensive prescriptions to a less costly pharmaceutical, where both therapies are equally effective. The relatively high costs of influencing prescriptions can quickly overwhelm potential cost savings.
g) The community pharmacists' feedback: on the delivery of the intervention was obtained using two methods of assessment (Nazareth et al, 2002). The first was a semi-structures assessment schedule that was completed after each outreach visit. Amongst the several items entered on this sheet, the pharmacists indicated whether they had identified any barriers to achieving change in prescribing practice at the practice. Some of the observed barriers are reported in table 2. The second was a nominal group interview that was conducted with the community pharmacists soon after they had completed their first visit, designed to assess their perception of what influenced the impact of their first visit. These main barriers that were identified were are follows:
i) Organisational factors: such as difficulty identifying suitable people who would benefit from the intervention.
ii) Doctors scepticism of the evidence: as with the antidepressant guideline the doctors could not accept that SSRIs were as acceptable as Tricyclics to the patients.
iii) Lack of interest in the topic: If the doctors were not interested in the topic this would present a significant barrier to the implementation of the guideline. A large number of doctors expressed a disinterest in the cost saving message conveyed to them by the anti-depressant therapy guideline.
iv) Doctors perception that the patients will resist implementation of the guideline.
v) The guideline conflicted with local policy: For example the hospital consultant always used SSRIs in people with depression and hence it was not possible to change people to Tricyclics.
Pilot study of critical appraisal and change management workshops on the implementation of cardiovascular disease guidelines
This section will provide a brief account of an exploratory trial to examine the independent and combined effects of teaching evidence based medicine and facilitated change management on the implementation of cardiovascular guidelines in primary care.
Design: The study was a randomised controlled trial with a factorial design. All practices were sent guidelines on five cardiovascular disease topics. After this two practices were allocated to each of the interventions namely: evidence based medicine teaching; facilitated change management; both or neither using a restricted randomisation procedure.
Participants: Eight (32%) from 25 eligible practice in the Medical Research Council General Practice Research Framework in North West Thames, London, UK took part in this study.
Interventions: The evidence based medicine intervention was a one-day practice based workshop, covering appraisal of trials, systematic reviews and guidelines. The change management programme comprised a one day workshop introducing principles of continuous quality improvement (change management, multiprofessional working, problem solving and analysis of the process of care) followed by a series of visits from facilitators trained in the methods.
Study outcomes: included prescribing indicators reflecting the implementation of cardiovascular disease guidelines and qualitative data on changes in professional practice using both in depth interviews and nominal group interviews.
Results: The participation in both the workshops (i.e. critical appraisal and change management) was overwhelming with all the GPs attending all the training sessions in the study practices. Their views of the workshops are provided in table 3. When interviewed at three months, the doctors reported that their clinical practice was better informed and more strongly evidence based. In addition, some practices reported a change to more reflective clinical practice and an increased awareness of relationships between various team members. However, when assessing the process of change through quantitative measures of change based on an improved adherence to the guidelines, it was observed that all the practices registered improved adherence to the guidelines over time (i.e. 12 months) but there were no differences between the four groups of practices studied. Hence despite the positive views expressed by the doctors soon after the intervention and at three months, these did not translate into measurable change over 12 months.
On the basis of the review presented and the results of the two studies presented in this chapter and the author's experience in the field of education in primary care, the following recommendations can be made on the mental health educational interventions in primary care. Some of the general issues that must be considered when developing new strategies on mental health training are as follows:
1) Educational interventions must be cheap to run and feasible to implement in a clinical setting
2) Education delivered at the practice is much better than education delivered in a post graduate centre or away from the clinical setting
3) Distribution of information leaflets or booklets providing information on clinical management or current evidence have been proven to be ineffective and hence should not be used
4) Didactic lectures are less useful than small groups teaching that uses interactive teaching techniques
5) Education that is specific to clinical situations is more likely to effective than generic educational strategies
There are various models of educational that can be implemented. Some of these have been previously tested for effectiveness and satisfy the criteria mentioned above. These are listed below, with a brief discussion of their relative merits and drawbacks.
1) Educational outreaches: are cheap and easy to deliver but only provide generic information on a specific area of clinical care rather than information that is specific to a clinical situation
2) Audit and feedback: on the other hand provides patient specific information that is relevant to a focussed clinical issue. The implementation of such a strategy requires considerably more personnel and much more by way of clinical resources
3) Computer decision support systems: are very patient specific and hence often results in an immediate change in clinical practice. Once again, however, this intervention is limited to high financial investments and cannot be implemented where the technology is not available or where adequate training on the use of the technology is available to the clinicians.
It would be apt to conclude that if a new method of education is proposed, it is essential to do some evaluation on its effectiveness before widespread recommendations on its applicability are made. Moreover, even if the effectiveness of a new educational strategy has been ascertained, further work will be required on the implementation of the educational intervention within different geographic and clinical settings.
Techniques of educational outreach
· Investigate knowledge and motivation for current activity
· Define clear educational and behaviourial objectives
· Establish credibility of information source through a respected organisational identity, referencing authoritative and unbiased sources of information and presenting both sides of the argument
· Stimulate active participation of physician in educational interactions
· Use concise graphic educational material that highlight and repeat essential messages
· Provide positive reinforcement of improved practices in follow-up visits
Box 1: Educational outreach intervention
Figure 1 - Evidence based outreach - trial flow chart
% Change in prescribing &Odd Ratios
Table 1: Change in prescribing
Factors favouring delivery of intervention
Rank1: Experience of the pharmacist - offered confidence with the intervention
Rank 2: Co-operation between the primary care staff and the pharmacists
Rank 3: Project credibility - the messages were relevant and the guidelines were developed by a well established academic group
Rank 4: Establishing a rapport with doctors at the practice
Rank 5: Support from the health authority with the initiative
Rank 6: Personal resourcefulness - ability for pharmacists to apply the evidence to daily clinical practice and deal with difficult questions
Rank 7: Use of visual aids - that assisted with conveying the main message of each guideline
Rank 8: Ability to deal with feeling overwhelmed or disheartened
Table 2 Pharmacists' perception of factors positively influencing impact of first intervention
Positive views - critical appraisal workshop
2)Stimulating and interesting
3) Interactive and problem based style
4) Multidisciplinary group
5) Practice based teaching
6) GP favoured as a tutor
7) Educational material useful
8) CME points useful
Negative views: Critical appraisal workshop
1) Too intensive - too much in one day
2) Poor organisation
3) No advance information provided on objectives of the day
4) Too difficult
5) Too long a day
6) Theoretical not practical
7) Limited impact on bringing about change
Positive views - change management
2) Great ideas
3) Enjoyable and informative
4) Useful day
5) Good approach to problems
6) Get away from regular routine for a day
7) Supportive environment
Negative views - change management
1) Too much theory
2) Morning session was boring
3) The games used for teaching were silly
4) Too much work
5) No advance information on objectives of the day
6) No need for all staff to attend
7) Unsure whether the theory will work
Table 3 Participants views on workshops - results of nominal group process
(The themes are listed according to ranks as provided by the participants)
1. Getting evidence into practice. Effectiveness Health Care Bulletin 1999:5(1). 2. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational material to improve the behaviour of health care professionals and patient outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 1999, Oxford: Update Software. 3. Lomas J. Words without action? The production dissemination and impact of consensus recommendations. Annual Review of Public Health 1991;12:41-65. 4. Implementing clinical guidelines: can guidelines be used to improve clinical practice. Effectiveness Health Care Bulletin 1994:5(1). 5. Thomson MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Outreach visits to improve health professional practice and health care (Cochrane Review). In: The Cochrane Library, Issue 1, 1999, Oxford. 6. Thomson MA, Oxman AD, Davis DA, Haynes RB , Freemantle N, Harvey EL. Haynes RB Audit and feedback to improve health professionals practice and health care outcomes Parts I&II (Cochrane Review). In: The Cochrane Library, Issue 1, 1999, Oxford. 7. Thomson MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders to improve health professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 1999, Oxford. 8. Hunt DL, Haynes RB, Hanna SE et al. Effects of computer based clinical decision support system on physician performance and patient outcomes. A systematic review. JAMA 1998;280:1339-46. 9. Shortell SM, Bennett CL, Bynck GR. Assessing the impact of continuous quality improvement on clinical practice: what will it take to accelerate progress. Millbank Q 1998:76:1-37. 10. Freemantle N, Nazareth I, Eccles M, Wood J, Haines A and the evidence based outreach trialists. A randomised controlled trial of the effect of educational outreach by community pharmacists on prescribing in UK general practice. British Journal of General Practice 2002: :290-95. 11. Eccles M, Freemantle N, Mason JM. Methods of developing guidelines for efficient drug use in primary care: North of England Evidence-based Guidelines Development Project. British Medical Journal 1998;316:1232-1235. 12. Eccles M, Freemantle N, Mason J and the North of England Aspirin Guideline Development Group. Evidence based clinical practice guideline: aspirin for the secondary prophylaxis of cardiovascular disease in primary care. British Medical Journal 1998;316:1303-9. 13. Eccles M, Freemantle N, Mason J and the North of England Evidence based Guideline Development Group. Evidence based clinical practice guideline: angiotensin converting inhibitors in the primary care management of adults with symptomatic heart failure. British Medical Journal 1998;316:1369-75. 14. Eccles M, Freemantle N, Mason J and the North of England Evidence based Guideline Development Group. Summary guideline for Non-steroidal anti-inflammatory drugs (NSAID) versus analgesia in treating of degenerative arthritis. British Medical Journal 1998;317:526-30. 15. Eccles M, Freemantle N, Mason J for the North of England Guideline Development Group. The choice of antidepressants for depression in primary care. Family Practice, 1999;16:103-11. 16. Avorn J & Soumerai SB. Improving drug-therapy decisions through educational outreach: a randomised controlled trial of academic based "detailing". New England Journal of Medicine 1983;308:1457-63. 17. Mason J, Freemantle N, Nazareth I, Eccles M, Haines A & Drummond M. When is it cost-effective to change the behaviour of health professionals? JAMA 2001:286:2988-2992. 18. Nazareth I, Freemantle N, Duggan C, Mason J & Haines A. Evaluation of a complex intervention for changing professional behaviour - the evidence based outreach trial (EBOR). Journal of Health Services Research & Policy 2002 (accepted for publication).
7th May 2003.
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