OBJECTIVE: The aim of this study was to investigate the effectiveness of interventions aimed at moving research evidence into stroke rehabilitation practice through changing the practice of clinicians.
DATA SOURCES: EMBASE, CINAHL, Cochrane and MEDLINE databases were searched from 1980 to April 2019. International trial registries and reference lists of included studies completed our search.
REVIEW METHODS: Randomized controlled trials that involved interventions aiming to change the practice of clinicians working in stroke rehabilitation were included. Bias was evaluated using RevMan to generate a risk of bias table. Evidence quality was evaluated using GRADE criteria.
RESULTS: A total of 16 trials were included (250 sites, 14,689 patients), evaluating a range of interventions including facilitation, audit and feedback, education and reminders. Of which, 11 studies included multicomponent interventions (using a combination of interventions). Four used educational interventions alone, and one used electronic reminders. Risk of bias was generally low. Overall, the GRADE criteria indicated that this body of literature was of low quality. This review found higher efficacy of trials which targeted fewer outcomes. Subgroup analysis indicated moderate-level GRADE evidence (103 sites, 10,877 patients) that trials which included both site facilitation and tailoring for local factors were effective in changing clinical practice. The effect size of these varied (odds ratio: 1.63-4.9). Education interventions alone were not effective.
CONCLUSION: A large range of interventions are used to facilitate clinical practice change. Education is commonly used, but in isolation is not effective. Multicomponent interventions including facilitation and tailoring to local settings can change clinical practice and are more effective when targeting fewer changes.
This systematic review will be helpful for those planning interventions to improve clinicians' practices in stroke rehabilitation. It was disappointing that education alone did not improve outcomes. Electronic reminders were helpful in improving compliance with guidelines. On-site facilitation and tailoring interventions for local settings were helpful. Having a small number of interventions was important.
Though there is low evidence due to differences in enrollment, outcomes population and types of intervention, this study provides useful information in an important topic. I found interesting (but somehow expected...) the fact that education in isolation provides no benefit in changing clinical practice.
I believe the review is weakened by not noting the number of clinicians in most of the studies. After all, clinicians are the focus of the interventions reviewed. Patient numbers can be useful, but only in the context of how many clinicians treated those patients.