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Meta-Analysis
. 2020 Jul 31;8(8):CD004398.
doi: 10.1002/14651858.CD004398.pub4.

Printed educational materials: effects on professional practice and healthcare outcomes

Anik Giguère  1   2 , Hervé Tchala Vignon Zomahoun  3 , Pierre-Hugues Carmichael  4 , Claude Bernard Uwizeye  5 , France Légaré  6 , Jeremy M Grimshaw  7 , Marie-Pierre Gagnon  8 , David U Auguste  9 , José Massougbodji  10
Affiliations
Meta-Analysis

Printed educational materials: effects on professional practice and healthcare outcomes

Anik Giguère et al. Cochrane Database Syst Rev. .

Abstract

Background: Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

Objectives: To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

Search methods: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

Selection criteria: We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

Data collection and analysis: Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

Main results: We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

Authors' conclusions: The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

PubMed Disclaimer

Conflict of interest statement

AG: none known

DUA: none known

PHC: none known

FL: none known

JMG is author of one of the included studies but he did not have any role in extracting and assessing risks of bias for this study

MPF: none known

HTVZ: none known

CBU: none known

JM; none known

Figures

1
1
Study flow diagram for the current update.
2
2
Potential effect modifier ‐ source of information. Legend: 1 = researchers/clinicians; 2 = university; 3 local expert body; 4 = national professional expert body; 5 = national government expert body; 6 = local clinicians; 7 = international expert body; 8 = international government expert body; 9 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
3
3
Potential effect modifier ‐ endorsement (yes, no, unclear). The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
4
4
Potential effect modifier ‐ tailoring. Legend: 1 = tailored to individuals based on diagnostic, behavioural, or motivational characteristics; 2 = tailored to groups of individuals; 3 = personalised, but not tailored (person's name on the information); 4 = generic; 5 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
5
5
Potential effect modifier ‐ Source quality level. Legend: 1 = system (computerised decision support); 2 = summaries (evidence‐based textbook); 3 = systematic review of randomised trials; 4 = clinical practice guidelines developed through formal consensus process; 5 = other synthesis; 6 = original randomised trial; 7 = original studies not randomised trial; 8 = expert opinion; 9 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
6
6
Potential effect modifier ‐ Mode of delivery. Legend: 1 = publication in peer‐reviewed journal; 2 = passive dissemination; 3 = direct mailing; 4 = mass mailing; 5 = media; 6 = hand delivery; 7 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
7
7
Potential effect modifier ‐ frequency of delivery (once, twice, 3 times, more than 3 times, indeterminate). The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
8
8
Potential effect modifier ‐ duration of delivery (once, 1‐3 months, 4‐6 months, over 6 months, indeterminate). The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
9
9
Potential effect modifier ‐ clinical area. Legend: ERT = Oestrogen‐replacement therapy. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
10
10
Potential effect modifier ‐ type of targeted behaviour. Legend: 1 = prescribing/treatment; 2 = financial (resource use); 3 = general management of a problem; 4 = diagnosis; 5 = procedures; 6 = referrals; 7 = test ordering; 8 = surgery; 9 = patient education/advice; 10 = clinical prevention service; 11 = screening; 12 = reporting; 13 = professional‐patient communication; 14 = record keeping; 15 = discharge planning; 16 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
11
11
Potential effect modifier ‐ purpose. Legend: 1 = initiation of management (e.g. introduction of new technology); 2 = stopping introduction of new management; 3 = increase of established management; 4 = cessation of established management; 5 = reduction of established management; 6 = modification of management (e.g. increased management in one activity, reduction in another). The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
12
12
Potential effect modifier ‐ educational component. Legend: 1 = continuing professional development (CPD) credits to recipients of PEMs; 2 = PEM delivered within a formal education programme; 3 = clear statement in the study that the PEM is intended for education; 4 = no clear educational component. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
13
13
Potential effect modifier ‐ format. Legend: 1 = publication of randomised trial results in peer‐reviewed journal; 2 = quick reference of clinical guidelines; 3 = full clinical guidelines; 4 = newsletter or bulletin; 5 = manual of peer‐reviewed clinical article reprints; 6 = other; 7 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
14
14
Potential effect modifier ‐ appearance. Legend: 1 = black and white, with a few figures or tables; 2 = graphically enhanced communication format (colour, picture, or figure); 3 = unclear. The box plots display median effect sizes, interquartile ranges (IQR), 1.5 the IQR (whiskers), and outliers (data point).
15
15
Risk of bias summary: review authors' judgements about each risk of bias item for each included RT and CBA study
16
16
Risk of bias summary: review authors' judgements about each risk of bias item for each included ITS study.
See this image and copyright information in PMC

Update of

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    1. Roberts VI, Esler CN, Harper WM. What impact have NICE guidelines had on the trends of hip arthroplasty since their publication? The results from the Trent Regional Arthroplasty Study between 1990 and 2005. Journal of Bone and Joint Surgery - Series B 2007;89(7):864-7. - PubMed
Roifman 2017 {published data only}
    1. Roifman I, Austin PC, Qiu F, Wijeysundera HC. Impact of the publication of appropriate use criteria on utilization rates of myocardial perfusion imaging studies in Ontario, Canada: a population-based study. Journal of the American Heart Association 2017;6(7):pii: e005961. - PMC - PubMed
Sakai 2017 {published data only}
    1. Sakai Bizmark R, Chang RR, Tsugawa Y, Zangwill KM, Kawachi I. Impact of AHA's 2007 guideline change on incidence of infective endocarditis in infants and children. American Heart Journal 2017;189:110-9. - PubMed
Salzler 2017 {published data only}
    1. Salzler GG, Farber A, Rybin DV, Doros G, Siracuse JJ, Eslami MH. The association of Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and Centers for Medicare and Medicaid Services Carotid Guideline Publication on utilization and outcomes of carotid stenting among "high-risk" patients. Journal of Vascular Surgery 2017;66(1):104-11. - PubMed
Santerre 1996 {published data only}
    1. Santerre RE. The effect of the ACOG guideline on vaginal births after cesarean. Medical Care Research and Review 1996;53(3):315-29. - PubMed
Shah 2008 {published data only}
    1. Shah BR, Juurlink DN, Austin PC, Mamdani MM. New use of rosiglitazone decreased following publication of a meta-analysis suggesting harm. Diabetic Medicine 2008;25(7):871-4. - PubMed
Shah 2014 {published data only}
    1. Shah BR, Bhattacharyya O, Yu C, Mamdani M, Parsons JA, Straus SE, et al. Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial. Trials 2010;11:44. - PMC - PubMed
    1. Shah BR, Bhattacharyya O, Yu CH, Mamdani MM, Parsons JA, Straus SE, et al. Effect of an educational toolkit on quality of care: a pragmatic cluster randomized trial. PLOS Medicine 2014;11(2):e1001588. - PMC - PubMed
Stafford 2004 {published data only}
    1. Stafford RS, Furberg CD, Finkelstein SN, Cockburn IM, Alehegn T, Ma J. Impact of clinical trial results on national trends in alpha-blocker prescribing, 1996-2002. Journal of the American Medical Association 2004;291(1):54-62. - PubMed
Steffensen 1997 {published data only}
    1. Steffensen FH, Sorensen HT, Olesen F. Impact of local evidence-based clinical guidelines - a Danish intervention study. Family Practice 1997;14(3):209-15. - PubMed
Stocks 2017 {published data only}
    1. Stocks SJ, Kontopantelis E, Webb RT, Avery AJ, Burns A, Ashcroft DM. Antipsychotic prescribing to patients diagnosed with dementia without a diagnosis of psychosis in the context of national guidance and drug safety warnings: longitudinal study in UK general practice. Drug Safety 2017;40(8):679-92. - PMC - PubMed
Tsuji 2009 {published data only}
    1. Tsuji SR, Atallah AN, Aranha FC, Tonhom AP, Siqueira AC Jr, Matos D. Cluster randomized clinical trial (ISRCTN23732000) to evaluate the effectiveness of a diagnosis recognition and treatment guide for depressive disorders in primary care. Journal of Evaluation in Clinical Practice 2009;15(1):222-5. - PubMed
Tziraki 2000 {published data only}
    1. Tziraki C, Graubard BI, Manley M, Kosary C, Moler JE, Edwards BK. Effect of training on adoption of cancer prevention nutrition-related activities by primary care practices: results of a randomized, controlled study. Journal of General and Internal Medicine 2000;15(3):155-62. - PMC - PubMed
Ulbricht 2014 {published data only}
    1. Ulbricht S, Gross B, Kunstmann W, John U, Meyer C. Efficacy of disseminating educational materials in general practices. Sucht 2014;60(2):85-91.
Wang 2005 {published data only}
    1. Wang YR, Alexander GC, Meltzer DO. Lack of effect of guideline changes on LDL cholesterol reporting and control for diabetes visits in the U.S., 1995-2004. Diabetes Care 2005;28(12):2942-4. - PubMed
Watson 2001 {published data only}
    1. Watson M, Gunnell D, Peters T, Brookes S, Sharp D. Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial. Journal of Health Services Research & Policy 2001;6(4):207-13. - PubMed
Weaver 2016 {published data only}
    1. Weaver MR, Pillay E, Jed SL, De Kadt J, Galagan S, Gilvydis J, et al. Three methods of delivering clinic-based training on syndromic management of sexually transmitted diseases in South Africa: a pilot study. Sexually Transmitted Infections 2016;92(2):135-41. - PMC - PubMed
Weiner 2017 {published data only}
    1. Weiner SG, Baker O, Poon SJ, Rodgers AF, Garner C, Nelson LS, et al. The effect of opioid prescribing guidelines on prescriptions by emergency physicians in Ohio. Annals of Emergency Medicine 2017;70(6):799-808. - PubMed
Weiss 2011 {published data only}
    1. Weiss K, Blais R, Fortin A, Lantin S, Gaudet M. Impact of a multipronged education strategy on antibiotic prescribing in Quebec, Canada. Clinical Infectious Diseases 2011;53(5):433-9. - PubMed
Zwarenstein 2014 {published data only}
    1. Zwarenstein M, Shiller SK, Croxford R, Grimshaw JM, Kelsall D, Paterson JM, et al. Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial [ISRCTN72772651]. Implementation Science 2014;9:87. - PMC - PubMed
Zwarenstein 2016 {published data only}
    1. Francis JJ, Grimshaw JM, Zwarenstein M, Eccles MP, Shiller S, Godin G, et al. Testing a TheoRY-inspired MEssage ('TRY-ME'): a sub-trial within the Ontario Printed Educational Message (OPEM) trial. Implementation Science 2007;2:39. - PMC - PubMed
    1. Zwarenstein M, Grimshaw JM, Presseau J, Francis JJ, Godin G, Johnston M, et al. Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651]. Implementation Science 2016;11(1):124. - PMC - PubMed
    1. Zwarenstein M, Hux JE, Kelsall D, Paterson M, Grimshaw J, Davis D, et al. The Ontario printed educational message (OPEM) trial to narrow the evidence-practice gap with respect to prescribing practices of general and family physicians: a cluster randomized controlled trial, targeting the care of individuals with diabetes and hypertension in Ontario, Canada. Implementation Science 2007;2:37. - PMC - PubMed

References to studies excluded from this review

Croudace 2003 {published data only}
    1. Croudace T, Evans J, Harrison G, Sharp DJ, Wilkinson E, McCann G, et al. Impact of the ICD-10 primary health care (PHC) diagnostic and management guidelines for mental disorders on detection and outcome in primary care. British Journal of Psychiatry 2003;182:20-30. - PubMed
Emslie 1993 {published data only}
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Engers 2005 {published data only}
    1. Engers AJ, Wensing M, Van Tulder MW, Timmermans A, Oostendorp RA, Koes BW, et al. Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial. Spine 2005;30(6):559-600. - PubMed
Evans 2010 {published data only}
    1. Evans DW, Breen AC, Pincus T, Sim J, Underwood M, Vogel S, et al. The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial. Spine 2010;35(8):858-66. - PubMed
Ferrari 2005 {published data only}
    1. Ferrari R, Rowe BH, Majumdar SR, Cassidy JD, Blitz S, Wright SC, et al. Simple educational intervention to improve the recovery from acute whiplash: results of a randomized, controlled trial. Academic Emergency Medicine 2005;12(8):699-706. - PubMed
Fontaine 2006 {published data only}
    1. Fontaine A, Mahe I, Bergmann JF, Fiessinger JN, Dhote R, Cohen P, et al. Effectiveness of written guidelines on the appropriateness of thromboprophylaxis prescriptions for medical patients: a prospective randomized study. Journal of Internal Medicine 2006;260(4):369-76. - PubMed
Hazard 1997 {published data only}
    1. Hazard RG, Haugh LD, Reid S, McFarlane G, MacDonald L. Early physician notification of patient disability risk and clinical guidelines after low back injury: a randomized controlled trial. Spine 1997;22(24):2951-8. - PubMed
Hunskaar 1996 {published data only}
    1. Hunskaar S, Hannestad YS, Backe B, Matheson I. Direct mailing of consensus recommendations did not alter GPs' knowledge and prescription of oestrogen in the menopause. Scandinavian Journal of Primary Health Care 1996;14(4):203-8. - PubMed
Jackevicius 1999 {published data only}
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Jain 2006 {published data only}
    1. Jain MK, Heyland D, Dhaliwal R, Day AG, Drover J, Keefe L, et al. Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized controlled trial. Critical Care Medicine 2006;34(9):2362-9. - PubMed
Janmeja 2009 {published data only}
    1. Janmeja AK, Mohapatra PR, Kumar M. The impact of "World Health Organization - Government of India guidelines on chronic obstructive pulmonary diseases-2003" on quality of life. Lung India 2009;26(4):102-5. - PMC - PubMed
Kocher 2003 {published data only}
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Kulkarni 1998 {published data only}
    1. Kulkarni K, Castle G, Gregory R, Holmes A, Leontos C, Powers M, et al, The Diabetes Care and Education Dietetic Practice Group. Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietician practices and patient outcomes. Journal of the American Dietetic Association 1998;98(1):62-70. - PubMed
Maiman 1988 {published data only}
    1. Maiman LA, Becker MH, Liptak GS, Nazarian LF, Rounds KA. Improving pediatricians' compliance-enhancing practices. A randomized trial. American Journal of Diseases of Children 1988;142(7):773-9. - PubMed
Majumdar 2008 {published data only}
    1. Majumdar SR, Johnson JA, McAlister FA, Bellerose D, Russell AS, Hanley DA, et al. Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. Canadian Medical Association Journal 2008;178(5):569-75. - PMC - PubMed
Martino 2011 {published data only}
    1. Martino P, Ban KM, Bartoloni A, Fowler KE, Saint S, Mannelli F. Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation. American Journal of Infection Control 2011;39(1):14-8. - PubMed
Mettes 2010 {published data only}
    1. Mettes TG, Van der Sanden WJ, Bronkhorst E, Grol RP, Wensing M, Plasschaert AJ. Impact of guideline implementation on patient care: a cluster RCT. Journal of Dental Research 2010;89(1):71-6. - PubMed
Mockiene 2011 {published data only}
    1. Mockiene V, Suominen T, Valimaki M, Razbadauskas A, Martinkenas A, Caplinskas S. The impact of an education intervention to change nurses' HIV-related knowledge and attitudes in Lithuania: a randomized controlled trial. Journal of the Association of Nurses in AIDS Care 2011;22(2):140-9. - PubMed
Mollon 2009 {published data only}
    1. Mollon DL, Fields WL. Is this the right patient? An educational initiative to improve compliance with two patient identifiers. Journal of Continuing Education in Nursing 2009;40(5):221-7. - PubMed
Morse 2009 {published data only}
    1. Morse L, McDonald M. Failure of a poster-based educational programme to improve compliance with peripheral venous catheter care in a tertiary hospital. A clinical audit. Journal of Hospital Infections 2009;72(3):221-6. - PubMed
Ozgun 2010 {published data only}
    1. Ozgun H, Ertugrul BM, Soyder A, Ozturk B, Aydemir M. Peri-operative antibiotic prophylaxis: adherence to guidelines and effects of educational intervention. International Journal of Surgery 2010;8(2):159-63. - PubMed
Perez‐Jauregui 2008 {published data only}
    1. Perez-Jauregui J, Gonzalez-Cardel AM, Olay-Fuentes G, Reza-Albarran A, Mehta R, Aguilar-Salinas CA. Inclusion of educational messages in laboratory reports aids to complete the diagnostic workup of hyperglycemia. Diabetes Care 2008;31(5):882-3. - PubMed
Richardson 2002 {published data only}
    1. Richardson B, Kitchen G, Livingston G. The effect of education on knowledge and management of elder abuse: a randomized controlled trial. Age Ageing 2002;31(5):335-41. - PubMed
Schwartz 2007 {published data only}
    1. Schwartz DN, Abiad H, DeMarais PL, Armeanu E, Trick WE, Wang Y, et al. An educational intervention to improve antimicrobial use in a hospital-based long-term care facility. Journal of the American Geriatrics Society 2007;55(8):1236-42. - PubMed
Simon 2007 {published data only}
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References to other published versions of this review

Farmer 2003
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