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

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)

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)

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)

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)

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)

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)

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)

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)

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)