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Table 2 Study characteristics of included trials in the review by nudge strategy

From: Nudge strategies to improve healthcare providers’ implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

Author name, year of publication, study design, country Setting/healthcare professional Number of experimental conditions Guidelines targeted Control group description Multicomponent strategy (yes (Y)/no (N) ); Description of intervention Description of nudge strategy Implementation outcomes (primary), time-point/s Data collection method Effect size—SMD/OR (95% CI) reversed
Priming nudge
Baer 2015 [90] , cluster RCT, USA 12 primary care practices affiliated with an academic medical centre 2 Obesity management Usual care Y; Educational presentation; resources; additional information about the electronic health record & guidelines Prompts to assess if body mass index is not assessed within the last year, reminders and other resources provided at point of care Percentage of patients with a documented body mass index in the medical record within 12 months after initial visit Collected as part of routine medical records (the electronic health records or scheduling systems) OR 0.91 (0.30,2.75)
Barnett 1983 [91], RCT, USA One physician group practice 2 None specific Usual care N; Physicians were sent reminders that they had deviated from standard care, and also an encounter form to record when next follow-up should occur. Another reminder was sent if follow-up specified by physician was not completed Automated computer-generated reminder and encounter form to record when next follow-up should be Adherence to quality assurance recommended programme; follow-up attempted or achieved at 6-12 months and 12-24 months Self-encoding checklists unique to each specialty are completed by the physician or nurse at the time of the patient encounter and subsequently entered in to the system (usually on the same day) by record room personnel OR 15.90 (6.32,39.99)
Burack 1996 [92], RCT, USA Two sites of a health maintenance organisation serving an urban, minority population 4 Cancer screening Usual care N; Group 1: Patient reminders only; Group 2: Physician reminder only; Group 3: Patient and physician reminder A brightly colour notice placed in medical record for women who had mammography due (Group 2 and 3) Visit to the primary care doctor and completion of a mammogram in the study year; approximately 12 months Electronic records OR 1.33 (1.01,1.75)
Chambers 1989 [93], RCT, USA One family practice centre with 28 healthcare providers 2 Cancer screening Usual care N; Date of the last mammogram ordered and entered into the database was displayed in the comments section of the encounter form for each visit. This information was printed as ‘last mammogram: date’, or, if no mammogram was on record in the encounter form database (i.e. none since 1984), the notation was listed as ‘last mammogram?’ Date of the last mammogram ordered and entered into the database was displayed in the comments section of the encounter form for each visit Up to date with the American Cancer Society guidelines for mammography (at end of intervention, 6 months follow-up) Physician recorded ordering of mammograms on a patient encounter form which is entered into a patient registration database OR 1.40 (1.08,1.82
Chambers 1991 [94], cluster RCT, USA Family Practice Center of the Department of Family Medicine at Thomas Jefferson University 3 Vaccination Usual care N; Reminders identifying patients as eligible for the vaccine were printed on the encounter form according to the assigned group of the patient's primary physician. These reminders were provided for appropriate patients at every visit during the 2-month study period until the physician responded by ordering the vaccine. When the billing record showed the procedure had been performed, the computer programme removed the reminder message from the encounter form Reminders identifying patients as eligible for the vaccine were printed on the encounter form according to the assigned group of the patient's primary physician Percentage who received influenza vaccine; post-intervention (2 months) Patient chart review (computerised database), adherence to the Immunization Practices Advisory Committee recommendation OR 1.80 (1.09,2.98)
Fisher 2013 [95], RCT, Singapore Three wards within 1 hospital (Singapore) 2 Hand hygiene Usual care Y; Wireless monitoring system of hand hygiene with reminders and individual feedback Wireless monitoring system of hand hygiene with reminders and feedback Hand hygiene compliance on entry/exit of patient zone within 10-week period Electronic hand hygiene monitoring system. Compliance was registered when hand hygiene occurred within preset times of entering (6 s) or exiting (1 min) a patient zone 2.5 mth (entry) SMD 0.17 (−0.09,0.44)
2.5 mth (exit) SMD 0.39 (0.12,0.66)
1.5 mth (entry): SMD: 0.62 (0.35,0.89)
1.5 mth (exit) SMD: 0.45 (0.19,0.72)
Goodfellow 2016 [96], cluster RCT, England 30 general practices in the East Midlands of England 2 Obesity management Usual care Y; Tailoring, training and educational resources for healthcare professionals (including a presentation, discussion and provision of the resources, e.g. patient booklets, body mass index charts, calories and portions leaflets, posters, information on referral pathways) Posters for consulting rooms containing information on how to measure waist circumference were given as a visual reminder Proportion of overweight or obese patients to whom the health professional had offered a weight loss intervention within the study period; 9-month follow-up Data collection was blinded and used a standard electronic system that extracted data from the general practice electronic health records and, to minimise bias, all data were collected using full anonymisation using electronic data extraction queries suitable for the different types of general practice computer systems used in England OR 0.88 (0.45,1.72)
King 2016 [97], RCT, USA One surgical intensive care unit at a hospital in Miami 4 Hand hygiene Usual care N; Visitors to an intensive care unit were exposed to an olfactory prime – a clean citrus smell that was introduced to the environment through a commercially available aroma dispenser. Visitors to an intensive care unit were exposed to a photo of eyes prominently displayed above the gel dispenser. In half the sessions a photo utilising clearly, female eyes was used and in the other photo male eyes Olfactory prime (clean citrus small via aroma dispenser); Visual prime (photo of male or female eyes displayed prominently above the gel dispenser) Observed hand hygiene compliance, 12 sessions of 3-h observations over a 3-month period Direct observation OR 3.18 (1.82,5.55)
Lafata 2007 [98], cluster RCT, USA 15 primary care clinics 3 Bone density screening Usual care N; Group 1: Initial and 1-month follow-up patient mailings were sent to women receiving the intervention. A third was sent to only those whose result indicated a need for follow-up. Group 2: As for Group 1 + physician prompts Physician prompt in the electronic medical record and a biweekly letter to physician Percentage who had bone mineral density testing/screening; 12 months Health record data OR 3.34 (2.29,4.88)
Le Breton, 2016 [99], cluster RCT, France 144 GPs, who provided care for any reason to 20,778 patients eligible for colorectal cancer screening between June 2010 and November 2011 2 Cancer screening Usual care N; Three reminders were mailed to GPs at 4-month intervals Reminders contained lists of patients who had not performed a scheduled faecal occult blood test (FOBT) Patient adherence to FOBT screening within the 17-month study period Patient review database from the main French statutory health insurance programme and local screening programme OR 1.08 (0.95,1.23)
Lobach 1997 [100], RCT, USA 58 primary care providers (20 family physicians, 1 general internist, 2 physician’s assistants, 2 nurse practitioners, 33 residents), outpatient setting, diabetic patients 2 Diabetes management Usual care N; Computer-Assisted Management Protocol consistent with the diabetes guideline recommendations. Protocol was printed on the first page of the paper encounter form and provided the customised diabetes guideline recommendations based on practice standards and previously completed tests, and an area for handwritten updates by the clinician to capture data not previously stored in the medical record The protocol generated a set of disease-specific care recommendations customised to an individual patient that advised the clinician regarding which studies/procedures should be done during the current visit and which studies/procedures were next due Clinician compliance rate with regards to care guidelines for diabetes mellitus overall (number of recommendations completed/total number of recommendations due); 6-month study period Medical chart audit & review of computer-generated lab test summaries SMD 0.97 (0.75,1.19)
Martin-Madrazo 2012 [101], cluster RCT, Spain 198 healthcare workers within 11 primary healthcare centres 2 Hand hygiene Usual care Y; Multimodal strategy based on World Health Organization (WHO) – posters; education sessions, availability of alcohol-based hand rub (4 × 50-min teaching sessions) Hydroalcoholic solutions were placed in each consultation office Hand hygiene compliance level; 6-month follow-up Direct observations. OR 2.93 (1.18,7.29)
Munoz-Price 2014 [102], cross-over RCT, USA 40 anaesthesiology providers at one, 1500-bed teaching hospital in Florida 2 Hand hygiene Minimal intervention: Wall-mounted hand sanitiser dispensers only N; Intervention involved using a hand sanitiser dispenser on the anaesthesia machine in addition to the standard wall-mounted dispensers Additional hand sanitiser dispenser on anaesthesia machine Frequency of hand hygiene, defined as the number of hand hygiene events per hour of observation, within 30 days, the same subjects were evaluated again in the opposite allocation Direct observation SMD 0.44 (−0.19,1.07)
Rogers 1982 [103], RCT, USA Physicians, 479 Northwestern University Clinic patients 2 Hypertension management Usual care N; A computer printout of a current computerised medical record system summary in addition to the traditional medical record A computerised medical record system was developed to provide physicians with concise and current information on patient’s problems, to identify omissions in recording of observations and treatment recommendations, to show ordered procedures that were not carried out, to record deficiencies in medical reasoning, and to recommend corrective actions according to selected criteria Hypertension renal function examination (done both years). Obesity: number of diets given of reviewed (done both years). Renal disease renal function examination (done both years); for 2-year period Blind retrospective chart reviews by trained personnel using a standardised evaluation form. Measurement tool was developed by the research team Hypertension renal function examination OR 1.54 (1.03,2.31)
Renal disease renal function examination OR 1.89 (0.85,4.20)
Obesity number of diets given or reviewed OR 2.01 (0.96,4.23)
Rossi 1997 [27], cluster RCT, USA 71 primary care providers within one general internal medicine clinic 2 Prescribing Usual care N; Reminder was attached to the medication refill forms that are given to providers at every patient visit One-page guideline reminder placed in the patient chart by the clinic pharmacist. The reminder highlighted the prescription and offered alternative drugs and doses Prescription change rate. The percentage changed from calcium channel blocker after 6 months Patient chart review via computer system OR 30.40 (4.08,226.35)
Schnoor 2010 [104], RCT, Germany 8 Local Clinical Centres (11 hospitals & 34 sentinel practices) 2 Prescribing Usual care Y; Audit & feedback, educational meetings with dissemination of guideline, reminders GPs and physicians received a poster, a short-printed version and an electronic version of the guideline Adherence to the guideline was analysed for the following variables: initial site of treatment, empiric initial antibiotic treatment and duration of antibiotic treatment. After a training period of 1 month, process of care after guideline implementation (1 April 2007 to 29 February 2008) was compared with the treatment before (1 September 2006 to 28 February 2007) Data of the recruited cases were entered by the personal tutor in-time, electronically using a standardised electronic report form (case report form) in a central database Antibiotic treatment in outpatients OR 1.27 (0.91,1.77)
Duration of antibiotic treatment in inpatients OR 0.93 (0.65,1.32)
Duration of antibiotic treatment in outpatients OR 2.11 (1.47,3.02)
Antibiotic treatment in inpatients OR 1.70 (1.19,2.42)
Initial site of treatment OR 1.75 (1.21,2.55)
Shojania 1998 [105], RCT, USA 396 physicians in one tertiary-care teaching hospital 2 Prescribing Usual care N; A computerised guidelines screen appeared whenever a clinician in the intervention group initiated an order for intravenous vancomycin. Another guidelines screen is displayed after 72 h of therapy asking providers their indication for continuing vancomycin use Showing computerised guidelines for vancomycin ordering at the time of initial vancomycin ordering and after 72 h of therapy Number of vancomycin orders and duration of vancomycin therapy prescribed by providers; 9-month period Vancomycin orders were obtained from computer log, monthly utilisation of vancomycin in the hospital was obtained from the pharmacy system. Total number of vancomycin orders SMD 0.22 (0.02,0.41)
Vancomycin days per physician SMD 0.23 (0.02,0.44)
Thompson 2008 [106], cluster RCT, England 19 acute mental health units in 4 local mental health trusts (667 nurses/doctors) 2 Prescribing Minimal intervention: Received guidelines on antipsychotic polypharmacy Y; An educational/cognitive behavioural therapy workbook; an educational visit to consultants; a reminder system on medication charts A medication chart reminder system was developed. Ward pharmacists applied removable reminder stickers to medication charts when participants were prescribed more than 1 antipsychotic Antipsychotic polypharmacy prescribing rates for each unit (cluster); 5 months Information was collected from patients’ medication charts using a 1-day cross-sectional survey of antipsychotic prescribing pre- and post-intervention OR 1.05 (0.66,1.68)
Yeung 2011 [107], cluster RCT, Hong Kong Six residential long-term care facilities (188 nursing staff) 2 Hand hygiene Intervention: Attended basic life support workshop (not hand hygiene) Y; Education sessions, feedback, reminders Pocket-sized containers of antiseptic hand rub were provided and kept close to clinicians. Adherence to hand hygiene; 2-week intervention period followed by 7-month post-intervention Direct observation OR 1.17 (0.72,1.90)
Norms and messenger nudges
Cranney 2008 [108], cluster RCT, Canada 119 primary care practices (174 clinicians) 2 Osteoporosis management Usual care N; Letter to patient and physician at 2 weeks and 2 months post-fracture A personalised letter notified the physician that their patient had a recent wrist fracture and highlighted that wrist fractures can be associated with osteoporosis, and that assessment for osteoporosis treatment is recommended for women with wrist fractures Proportion of women who reported they were started on osteoporosis treatment (i.e. bisphosphonates, raloxifene, hormone therapy or teriparatide) within 6 months of fracture, 6 months post-fracture Self-report via telephone survey OR 3.29 (1.65,6.55)
Engers 2005 [109], cluster RCT, Denmark 67 eligible GPs, 531 patients with nonspecific low back pain 2 Low back pain management Usual care Y; Two-hour workshop; distribution of a half-page patient education card; the guideline for occupational physicians; 2 scientific articles concerning GP management of nonspecific low back pain; and a collaboration tool to facilitate greater agreement with physical, exercise, and manual therapists on the management of nonspecific low back pain In addition to the workshop, GPs received printed materials including patient education, a copy of the guidelines, scientific articles (educational material) and a collaboration tool Number of referrals to a therapist (physical, exercise, or manual therapist) within 8-month study period GPs completed self-registration forms post consultation; patient questionnaire completed immediately after the consultation OR 5.17 (1.73,15.39)
Feldstein 2006 [110], RCT, USA Nonprofit, group-model health maintenance organisation in the Pacific Northwest with about 454,000 members, 35% of whom were aged 50 and older and more than 90% of whom had a prescription drug benefit.
15 primary care clinics and 159 primary care providers (range 1–3 patients per provider)
3 Osteoporosis management Usual care Y; Group 1: electronic medical record message about participant risk of osteoporosis and distribution of educational materials
Group 2: As for Group 1 + patient-directed component
Primary care providers received patient-specific electronic medical record in-basket messages for their enrolled patients from the chairman of the osteoporosis quality improvement committee The primary outcome was the proportion of the study population who received a pharmacological treatment or a bone mineral density measurement within 6 months after the intervention Identified electronically from the outpatient pharmacy system of data from the referral site (on bone mineral density measurement) OR 15.93 (2.13,118.93)
Majumdar 2008 [111], RCT, Canada Two largest emergency departments and 2 largest fracture clinics in Capital Health (Edmonton, Alberta) (266 primary care physicians) 2 Osteoporosis management Minimal intervention: Mailed osteoporosis guidelines Y; Distribution of guidelines endorsed by local leaders; physician reminder; patient telephone counselling Evidence-based treatment guidelines, representing an actionable summary of available osteoporosis guidelines and having endorsement from 5 local opinion leaders, were sent to these physicians Starting treatment with a bisphosphonate within 6 months after the fracture, 6 months post-fracture Patient self-report, confirmed through dispensing records at local pharmacies OR 1.46 (0.70,3.08)
Mertz 2010 [112], cluster RCT, Canada 30 adult hospital wards in 3 acute care sites 2 Hand hygiene Minimal intervention: Alcohol-based gel dispensers were installed outside all patient rooms with at least 1 hand wash sink in each room Y; Installation of gel dispensers as per control group + performance feedback, educational meeting & resources Clinical managers were asked to develop a target adherence level. Meetings were held biweekly to provide unit-specific feedback. The adherence rates were shown on a large whiteboard both graphically and numerically. After 6 months, a comparison with the rates of other intervention units was provided Rates of hand hygiene adherence, evaluated at unit level, assessed weekly for 1-year intervention period Direct observations OR 1.25 (0.90,1.74)
Shah 2014 [113], cluster RCT, Canada 80 primary care practices
1592 patients at high risk for cardiovascular disease were selected
2 Prescribing Minimal intervention: Control providers received the Canadian Diabetes Association newsletter, which included the revised guidelines for cardiovascular disease screening N; Printed educational materials (1 toolkit including guidelines summary, laminated card with risk assessment algorithm, self-assessment tool & risk reduction strategies) Letter from the Chair of the practice guidelines Dissemination and Implementation Committee, with guideline summary Prescription for statin; 10 months Trained registered nurse undertook patient chart review OR 0.76 (0.42,1.37)
Salience/affect nudges
Dey 2004 [114], cluster RCT, England 24 General Practices with 2187 eligible patients 2 Test ordering Usual care Y; Educational outreach visit; guidelines (educational material); poster of guidelines; referral forms with guidelines; access to fast-track physiotherapy and a back clinic)
General Practitioners (GPs) were sent a letter offering them a visit from the guideline team, followed by a telephone call to the practice manager to arrange an appointment with the GP in their practice. At least 2 members of the guideline team attended each visit. Members of the guideline team facilitated a structured interactive discussion with the GP
Face-to-face meeting included structured interactive discussion with the GP, which was based on the ‘elaboration likelihood model of persuasion’. This discussion was used to: raise awareness of the guidelines, adapt to the local context; emphasise the key messages in the guidelines; identify potential barriers to implementation; and suggest strategies for overcoming the barriers identified The rate of referral for lumbar spine X-rays; 8 months GPs were asked to log every patient presenting to them with acute low back pain: the practice was reimbursed £1 for each patient identified. A research assistant screened the records of these patients to confirm eligibility and to extract data on patient characteristics and clinical management during the 3-month period following first consultation OR 0.89 (0.60,1.32)
Grant 2011 [115], RCT, USA One hospital; with all 66 soap & gel dispensers randomly allocated to 1 of 3 signs 3 Hand hygiene Minimal intervention: The control sign, which was developed by hospital managers, read, ‘Gel in, wash out’ N; Three different signs over period of 2 weeks Personal consequences’ sign read ‘Hand hygiene prevents you from catching diseases’. The patient-consequences sign read, ‘Hand hygiene prevents patients from catching diseases’ Mean percentage of soap and gel used during 2-week periods before and after signs were introduced Measured by blinded environmental services team SMD 0.17 (−0.35,0.69)
Ince 2015 [116], RCT, England 13 community mental health teams (82 individuals) 2 Delivery of psychological interventions Minimal intervention: Summary of guidelines for psychological interventions for schizophrenia N; Alternative text of National Institute for Health and Clinical Excellence Guidelines guidance for schizophrenia Summary of guidelines re-written. Text was amended to personalise the message, use of behaviourally specific language. Checklist & decision tree produced & provided Overall intention to follow the recommendations measured by a Theory of Planned Behaviour Total Scale Intention Score, number of participants providing psychological interventions (delivered, received training, supervision), at 1-month follow-up Self-report questionnaire Intention to follow Theory of Planned Behaviour Total Scale Intention Score : SMD: 0.00 (−0.47,0.48)
Received psychological training in last month OR 0.77 (0.16,3.76)
Psychological interventions delivered OR 1.65 (0.58,4.66)
Supervision for psychological interventions was used OR 1.69 (0.58,4.92)
Leslie 2012 [117], RCT, Canada Unclear. There were n = 4264 patients randomised 3 Osteoporosis management Usual care Y; Group 1: Notification letter to primary care physician (reminder) about the patient’s fracture accompanied by educational material
Group 2: As for Group 1 + patient-directed intervention (educational material and reminder)
A letter directed the physician to the provincial guidelines on bone mineral density testing and provided information on the management of osteoporosis. Additional information specific to the investigators research initiative was also provided. Enclosed with the letter were a requisition for a bone mineral density test and a flowchart showing the management of care Combined end point of post-fracture bone mineral density testing or the start of medication for osteoporosis; 12 months post-fracture Healthcare database information OR 2.58 (2.17,3.07)
Priming (MPC: memorandum pocket card); default (TRF: test request form)
Daucourt 2003 [118], cluster RCT, France Six volunteer general hospitals and 1412 thyroid function tests ordered in 1306 patients 4 (2 included in current review (TRF [test request form] & MPC [memorandum pocket card]) Test ordering Intervention: Physicians in all groups received guidelines and were invited to a local information meeting where guidelines were presented and discussed N; Replacing previous order sheet with new TRF and providing small summary of recommendations on card TRF makes ordering of inappropriate tests impossible based on format of the form
MPC designed to be summary of guidelines that can be kept in pocket
Proportion of thyroid function test ordering in accordance with guidelines at 4 weeks after guideline implementation Research Assistant completed data collection grid from patient medical files and test requests, or by speaking with the prescriber OR 2.18 (1.16,4.10)
Priming, norms and messenger nudges
Eccles 2001 [119], RCT, England 247 General Practices enrolled. Data was abstracted from 1693 patients’ records of 162 GPs in 48 practices 4 (2 × 2 factorial design) Test ordering Minimal intervention: Distribution of educational materials (guideline) N; Group 1: Distribution of educational materials; audit and feedback (number of practice referrals compared with peers)
Group 2: Distribution of educational materials; reminders (messages on X-ray results)
Group 3: Distribution of educational materials; audit and feedback; reminders
All interventions had a 12-month duration
Referral guidelines were posted to all GPs. Feedback contained the number of requests for lumbar spine and knee radiographs made by the whole practice compared with requests made by all GPs in the study was sent to GPs at start of intervention period and 6 months later. Educational messages were attached to the reports of every knee or lumbar spine radiograph requested during the 12-month intervention The number of each radiograph (knee, lumbar, spine) requested per 1000 patients registered with every practice per year for 2 years; the second year was the intervention period Records of radiology departments Mean lumbar spine radiographs SMD 0.34 (0.05,0.63)
Mean knee radiographs SMD 0.39 (0.09,0.68)
Majumdar 2007 [120], RCT, Canada 40 pharmacies (targeted sample size), patients with a self-reported diagnosis of heart failure or ischemic heart disease who was not taking a study medication 2 Prescribing Minimal intervention: Physicians of the control subjects were faxed only their most recent medication profile N; Five physicians were consistently identified as opinion leaders and worked with the investigators to develop the study’s evidence summaries One-off fax of evidence summary to physician with the patient’s most recent medication profile Improvement of prescribing for efficacious therapies in patients with a chronic cardiovascular disease within 6 months of the intervention Patient-level medication profiles generated at each community pharmacy; outcomes measured by compliance with evidence-based prescribing recommendations OR 1.46 (0.70,3.08)
McAlister, 2006 [121], RCT, Canada Physicians at primary care practices, patients with established coronary artery disease 3 Prescribing Minimal intervention: Physicians received a fax containing the coronary artery diagram for their patient N; Opinion leader statement group: The opinion leader statements were imprinted with the name of the participating patient, addressed directly to the patient’s physician, signed by the local opinion leaders for that city, and faxed automatically by a software programme that was developed for this trial.
Unsigned statement group: The unsigned statements were identical to the opinion leader statements in content and form but did not contain the opinion leaders’ signatures. The unsigned statements were faxed to physicians in the same manner as the opinion leader statements
Each physician received a fax containing objective evidence of the patient’s coronary artery disease (in the form of a coronary artery diagram) and either a signed or unsigned statement. These faxes were sent to physicians within a few days of the angiogram Improved statin management, defined as initiation or increased dosage of a statin within the first 6 months after cardiac catheterisation Medication outcomes were based on patient self-report (with cross-referencing to pharmacy records), and laboratory data and clinical outcomes were extracted from medical records OR 1.31 (0.89,1.92)
Rodriguez 2015 [122], cluster RCT, Argentina 705 healthcare workers in 11 intensive care units at acute care hospitals 2 Hand hygiene Usual care Y; Educational resources, reminders, feedback, executive support Every month, coordinators of intervened sites received results of the indicator (compliance with hand hygiene) and they showed them in the storyboard comparing it to the best performance in study (if the site complied with <70%) or to an international performance of 95% (if the site complied with 71% or more. Reminders placed at the entrance of patient’s rooms and in common areas Adherence to hand hygiene based on the WHO survey tool; monthly for 9 months Direct observation (covert) OR 1.58 (1.09,2.29)
Schouten 2007 [123], cluster RCT, Netherlands Six medium-large hospitals in southeast of the Netherlands 2 Prescribing Not reported Y; Audit & feedback; educational meetings with dissemination of guidelines Consensus ‘critical-care pathways’ were distributed to all doctors as a laminated, pocket card; desktop and personal digital assistant versions were also distributed. Feedback on indicator performance at the hospital level was presented and provided in writing to all doctors treating hospital lower respiratory tract infections. Feedback reports included benchmarks at the hospital level (best practice) and presented key issues for improvement A sum score was calculated that determined the sum score for guideline adherence for empirical antibiotic therapy; 2 years All data were collected by concurrent chart review; trained research assistants made twice-weekly reviews of the charts of all patients who were admitted to the internal and respiratory medicine wards OR 2.16 (0.75,6.23)
Taveras 2015 [124], cluster RCT, USA Primary care practice paediatric clinicians, children with obesity 3 Obesity management Usual care Y; Modified electronic health record to deploy a computerised, point-of-care clinical decision support alert to paediatric clinicians at the time of a well-child visit for a child with a body mass index at the 95th percentile or greater. Clinicians were trained to use brief motivational interviewing to negotiate a follow-up weight management plan with the patient and their family. A comprehensive set of educational materials were developed for paediatric clinicians to provide to their patients An alert containing links to growth charts, evidence-based childhood obesity screening and management guidelines, and a prepopulated standardised note template specific for obesity Body mass index percentile documentation, Healthcare performance/quality of care (nutrition/physical activity counselling documentation); baseline and 1-year follow-up Child’s electronic health record from well-child visits, and Healthcare Effectiveness Data and Information Set (health performance) HEDIS Performance Measures BMI percentile documentation OR 1.49 (0.73,3.01)
HEDIS Performance Measures nutrition PA counselling documentation OR 63.37 (3.81,1052.67)
Rahme 2005 [125], cluster RCT, Canada GPs in eight small towns in Quebec, Montreal 3 Prescribing Did not report Y; Group 1: Workshop which discussed evidence-based management of patients with osteoarthritis
Group 2: Decision trees to support decision-making
Group 3: Combination of workshop and decision tree
Continuing medical education points and endorsement by medical bodies, delivered by peers (Groups 2 and 3) Number of dispensed prescriptions for osteoarthritis from the Provincial Health Care fund database; 5 months pre-intervention and 5 months post-intervention (12 months) Patient records OR 1.52 (0.65,3.57)
Priming, salience, norms and messenger nudges
Roux 2013 [126], RCT, Canada Primary care physicians of an acute care hospital, 1446 patients aged 50 years or older with fragility fractures 3 Osteoporosis management Usual care Y; Group 1: Verbal and written information on osteoporosis to patient (patient-directed component) and letter with specific management plan sent to their treating physician (GP reminder). Patient reminders at 6 and 12 months. Reminder to physician if patient untreated at 6 months
Group 2: As for Group 1 + blood tests and bone mineral density test ordered for patient and results sent to the physician (patient-mediated intervention). Patient reminders at 4, 8 and 12 months and physician reminders at 4 and 8 months if patient remained untreated
Verbal and written information on osteoporosis to patient and letter with specific management plan sent to their treating physician. Blood tests and bone mineral density test ordered for patient and results sent to the physician. Patients and physicians received reminder if patients remained untreated Percentage change in treatment rates for osteoporosis; 1-year post-fracture Delivery of osteoporosis medication was confirmed with the patient’s pharmacists OR 3.05 (2.01,4.63)
Solomon 2001 [127], RCT; USA 17 internal medicine services within one academic medical centre in USA 2 Prescribing Usual care Y; Educational meetings with policy dissemination; 1 x face-to-face or telephone academic detailing session with clinician who wrote the order for the 2 unnecessary antibiotics being studied Academic detailing, patterns of antibiotic utilisation and resistance patterns in the institution Number of days that unnecessary antibiotics (levofloxacin or ceftazidime) were administered in intervention & control services; 18-week period Computerised pharmacy records (validated in a sub-sample of patients against the manually completed medication administration records in patient chart) SMD 1.54 (0.44,2.64)
Norms and messenger, salience and incentive nudges
Robling 2002 [128], cluster RCT, Wales 39 general practices in South Glamorgan, Wales 4 Test ordering Minimal intervention: single A4-sheet feedback on practice data Y; Seminar workshop facilitated by academic GPs and researcher; videos; question and answer session Continuing medical education point, feedback from experts, presentation of localised guidelines Percentage concordant with local guidelines (MRI: medical resonance imaging requests); 11 months Each MRI request was followed up, additional information assessed via follow-up interview with GPs OR 0.59 (0.24,1.42)
Norms and messenger, priming and incentive nudges
Solomon 2007 [129], cluster RCT, USA 828 primary care physicians within primary care clinics 4 (2 × 2 factorial design) (only relevant doctor arm described) Prescribing Usual care Y; Educational resources that were used in a face to face educational session. Osteoporosis treatment algorithms, reminders flags and behavioural prescription packs were also provided One hour of continuing medical education credit by Harvard Medical School were offered; reminder flags Composite score consisting of either undergoing bone mineral density testing or initiation of medication for osteoporosis; 12 months Patient Medicare and pharmacy claims data OR 0.89 (0.74,1.06)
Norms and messenger, priming, salience and commitment nudges
Stewardson 2016 [130], cluster RCT, Switzerland Hospital ward 3 Hand hygiene Intervention: Standard multimodal hand hygiene promotion activities, including monitoring and feedback, were done hospital wide throughout the study Y; Group 1: Audit and feedback; goal setting; executive support
Group 2: As for Group 1+ patient participation (educational materials, alcohol-based handrub)
Immediate verbal feedback and, where feasible, a card reporting individual hand hygiene compliance and individualised written advice for how to improve were provided. The card also illustrated the WHO Five Moments for Hand Hygiene and stated the institution-wide hand hygiene compliance goal (≥80%), with the signatures of the medical and nursing directors Overall hand hygiene compliance of healthcare workers, at least once every 3 months during the baseline and intervention periods, and once every 4 months during the follow-up period Direct observation during 20-min sessions OR 1.10 (0.84,1.44)
  1. Note: RCT randomised controlled trial, USA United States of America, GP general practitioner, FOBT faecal occult blood test, WHO World Health Organization, MRI medical resonance imaging