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Table 3 Characteristics of the included studies (n = 22)

From: Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis

Author (year)

Country

Design

Number of patients included

Clinical setting

Low-value practice

Intervention

Control

Use of low-value practice with intervention

Use of low-value practice without intervention

Change in use of the low-value practice

Randomized clinical trials

 Macfarlane (2002) [28]

UK

Nested

212

Primary care

Antibiotics for acute bronchitis

Information leaflet on the natural course of lower respiratory symptoms and the advantage and disadvantages of antibiotics

General practitioner provided prompt card for informing patients that there is no indication for antibiotics

Proportion of patients who used antibiotics, 47%

Proportion of patients who used antibiotics, 62%

RR 0.76; 95% CI (0.59–0.97)

 Francis (2009) [29]

UK

Cluster

558

Primary care

Antibiotic prescribing

Interactive booklet on respiratory tract infections

Usual care

Proportion of patients prescribed antibiotics, 19.5%

Proportion of patients prescribed antibiotics, 40.8%

RR 0.48; 95% CI (0.36, 0.64)

 Legare (2012) [30]

Canada

Cluster

181

Primary care

Antibiotics for acute respiratory tract infections

Shared decision-making between patient and physicians

Usual care

Patients who used antibiotics following consultation, 27.2%

Patients who used antibiotics following consultation, 52.2%

RR 0.53; 95% CI (0.40, 0.70)

 Tannenbaum (2014) [31]

Canada

Cluster

303

Community pharmacy

Benzodiazepines for older adults

Booklet providing information about risks, a tapering protocol, and prompt to discuss with physician

Usual care

Proportion of patients who discontinued benzodiazepine use, 27.0%

Proportion of patients who discontinued benzodiazepine use, 4.5%

RR 0.76; 95% CI (0.69, 0.85)

 Schneiderman (2003) [32]

USA

Multi-center

551

Hospital

Non-beneficial life-sustaining treatments in the intensive care unit

Ethics consultations

Usual care

Mean (SD) days receiving ventilation, 6.52 (8.52)

Mean (SD) days receiving ventilation, 8.22 (11.16)

Absolute difference, 1.7 days; P = 0.03

 Montgomery (2007) [33]

UK

Three-armed

742

Hospital

Non-indicated cesarean section

Information program: Information about probabilities of clinical outcomes

Decision analysis: Decision tree recommended a “preferred option” based on women’s preferences and values

Usual care

Proportion of elective cesarean sections: information program, 49%; decision analysis, 41%

Proportion of elective cesarean sections, 50%

Information program:

RR 0.95; 95% CI (0.79, 1.14)

Decision analysis:

RR 0.80; 95% CI (0.66, 0.98)

 Hess (2012) [34]

USA

Two-armed, parallel

204

Emergency department

Cardiac stress testing in patients at low risk for acute coronary syndrome

Decision aid to improve patient knowledge and engage in shared decision-making

Usual care

Proportion of patients who received stress testing within 30 days of ED visit, 75%

Proportion of patients who received stress testing within 30 days of ED visit, 91%

RR 0.81; 95% CI (0.72, 0.93)

 Hess (2016) [35]

USA

Multi-center

898

Emergency department

Cardiac stress testing in patients at low risk for acute coronary syndrome

Inform patients about their risk and options for care; shared decision aid

Usual care

Proportion of patients who received stress testing within 30 days of ED visit, 38.1%

Proportion of patients who received stress testing within 30 days of ED visit, 45.6%

RR 0.84; 95% CI (0.72, 0.98)

 Navaee (2015)

Iran

Two-armed, parallel

67

Hospital

Cesarean section in primiparous women

Role-playing session about the advantages and disadvantages of cesarean section

Usual care

Proportion of patients who had a c-section, 2.9%

Proportion of patients who had a c-section, 15.6%

RR 0.18; 95% CI (0.02–1.48)

Non-randomized intervention studies

 Wheeler (2001) [36]

USA

Prospective observational study

144

Primary care

Antibiotic overuse

Educational videotape and written materials

No control group

Proportion of patients receiving antibiotic prescriptions, 4.2%

Proportion of patients receiving antibiotic prescriptions, 6.8%

RR 0.62; 95% CI (0.15, 2.49)

 Perz (2002) [37]

USA

Before-and-after*

NR

Primary care

Antibiotic overuse

Educational materials for parents of young children and the general public

Usual care

Percent change in antibiotic prescription rate from baseline per 100 person-years, − 19%

Percent change in antibiotic prescription rate from baseline per 100 person-years, − 8%

Intervention-attributable decline, 11%; 95% CI (8–14%)

 Dollman (2005) [38]

Australia

Before-and-after

~ 20,000

Primary care

Antibiotic use for upper respiratory tract infections, sinusitis, and otitis media

Pamphlets highlighting risks and benefits distributed to general practices and within the community

No control group

Defined daily dosages per 1000 population per day, 52.9

Defined daily dosages per 1000 population per day, 77.1

Overall reduction, 32%; p < 0.01

 Gonzales (2005) [39]

USA

Non-randomized controlled trial*

1144

Primary care

Antibiotics for children with pharyngitis, antibiotics for adults with acute bronchitis

Educational materials mailed to households and available in physicians’ offices

Usual care

Proportion of patients prescribed antibiotics:

adult, 36%; child, 30%

Proportion of patients prescribed antibiotics: adult, 60%; child, 34%

Adult:

RR 0.60; 95% CI (0.51, 0.70)

Child:

RR 0.88;

95% CI (0.65, 1.18)

 Ashe (2006) [40]

USA

Before-and-after

720

Primary care

Antibiotic overuse

Educational waiting room poster in physicians’ offices

Historical controls; usual care

Proportion of patients treated with antibiotics, 48.3%

Proportion of patients treated with antibiotics, 44.3%

RR 1.09; 95% CI (0.91, 1.31)

 Gonzales (2008) [41]

USA

Non-randomized controlled trial

992

Primary care

Antibiotic overuse

Media campaign

Counties that did not receive a media campaign

Net antibiotic prescriptions per 1000 persons compared to comparison community (12 months post-intervention), − 5

Net antibiotic prescriptions per 1000 persons compared to control community (10 months pre-intervention), −1

8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members; P = 0.03

 Hemo (2009) [42]

Israel

Prospective observational study*

84,979

Not specified

Antibiotic use for upper respiratory tract infection, otitis media, pharyngitis

Media campaign

No control group

Post-campaign period vs. baseline:

URI OR 0.749 (0.694, 0.808); otitis media OR 0.652 (0.591, 0.718); pharyngitis OR 0.931 (0.890, 0.973)

Pre-campaign period vs. baseline:

URI OR 0.962 (0.891, 1.039); otitis media OR 0.970 (0.874, 1.076); pharyngitis OR 0.968 (0.929, 1.009)

 

 Morgan (2002) [43]

UK

Before-and-after

242

Primary care

Long-term use of benzodiazepines

Patient letter explaining risks, encouraging a reduction in intake, and prompt to contact physician for discussion

No control group

Mean defined daily dosages/patient, 283.0

Mean defined daily dosages/patient, 336.6

Absolute difference, 53.6; P < 0.001

 Simpson (2010) [44]

USA

Before-and-after

531

Hospital

Elective labor induction

Educational classes on elective induction risk

No educational classes

Proportion of patients who received elective induction, 27.9%

Proportion of patients who received elective induction, 37%

RR 0.75; 95% CI (0.58, 0.96)

 Engineer (2018) [45]

USA

Quality improvement project

176

Emergency department

Computed tomography for mild head injury

Electronic tool that involved a structured discussion between providers and caregivers

No control group

Proportion of patients who received head CT, 22.0%

Baseline head CT utilization in the pediatric ED population, 62.7%

RR 0.35; 95% CI (0.26, 0.47)

 Arterburn (2006)

USA

Before-and-after

9515

Hospital

Unnecessary surgery for knee and hip osteoarthritis

Patient decision aids in DVD, website, and booklet format

No control group

Total hip replacement per 180 person-days, 0.34

Total knee replacement per 180 person-days, 0.09

Total hip replacement per 180 person-days, 0.46

Total knee replacement per 180 person-days, 0.16

Hip replacement relative rate, 0.74, P < 0.01

Knee replacement relative rate, 0.62, P < 0.01

 Jerardi (2013)

USA

Quality improvement project

224

Hospital

Voiding cystourethrogram (VCUG) in children with first UTI with normal renal and bladder ultrasound (RBUS)

Educational materials and information sheets for patients and families

No control group

Proportion of patients with normal RBUS who received VCUG: 25.4%

Proportion of patients with normal RBUS who received VCUG: 84.9%

RR 0.29; 95% CI (0.17, 0.51)

 Pugel (2018)

USA

Quality improvement project

 

Hospital

Complete blood counts (CBCs), electrocardiograms (EKGs) as routine screening tests in physical examination visits, age-inappropriate dual-energy absorptiometry (DEXA) scans, imaging for uncomplicated headache

Patient-targeted materials produced by Consumer Reports, including exam room posters, patient education materials in waiting areas and exam rooms

No control group

CBCs, 3.16%; EKGs, 0.33%; DEXA scans, 2.02%; imaging for uncomplicated headache, 6.88%

CBCs, 42.7%; EKGs, 15.9%; DEXA scans, 25.4%; imaging for uncomplicated headache, 10.8%

Absolute difference (95% CI): CBCs 39.54% (39.0–40.0); EKGs 15.57% (15.1–15.8); DEXA scans 23.38% (22.5–24.5); imaging for uncomplicated headache 3.92% (3.3–4.6)

  1. CT computed tomography, RR risk ratio, ED emergency department, SD standard deviation, URI upper respiratory infection
  2. *Adequately adjusted for confounding