Tailored interventions to address determinants of practice

In the paper

“Seven are ongoing studies (Ongoing studies) and seven are awaiting assessment (Studies awaiting classification).”

In the paper

“The remaining 17 studies were not eligible for meta‐regression because they either did not assess a suitable binary outcome, or they reported no data at baseline.”

In the paper

“In this update of our review of randomised trials of tailored implementation interventions, we identified an additional nine studies, seven of which had been published since the previous version of the review (Baker 2010).”

What the sources say

• Not checked yetcites Baker 2010 source

In the paper

“Twenty‐three of the studies had been included in the previous version of the review, but we excluded three studies from that review because the interventions were not assessed on this occasion as meeting the criteria for tailoring (Davies 2002; Sehgal 2002; Verhoeven 2005).”

What the sources say

• Not checked yetcites Davies 2002
• Not checked yetcites Sehgal 2002 source
• Not checked yetcites Verhoeven 2005 source

In the paper

“Separate models were fitted dependent on the intervention delivered to the control group (none or non‐tailored), but none were found to be associated with the reported effectiveness of the tailored interventions.”

In the paper

“We included 15 of 32 studies in the meta‐regression analysis (Table 2; Table 3).”

In the paper

“We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants.”

In the paper

“We screened 9403 unique citations (Figure 1) and reviewed the full text of 360.”

In the paper

“Despite the increase in the number of studies, however, our overall finding is similar to that of the previous review.”

In the paper

“Clear reports of such effects were not included in the studies.”

In the paper

“We excluded 106 with reasons provided in the Characteristics of excluded studies table and we excluded 208 with quick reference to the full text.”

In the paper

“The 17 studies not included in the meta‐analysis had findings showing variable effectiveness consistent with the findings of the meta‐regression.”

• Also stated in: § Summary of findings · plain

  “The effect of tailored interventions in these studies varied from no effect to moderate effect between studies and between outcomes within studies, a finding consistent with the meta‐regression”

In the paper

“Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants.”

In the paper

“Where data were collected on the same group of patients throughout the trial (three studies), no problem with drop‐outs was reported.”

In the paper

“For the main analysis with all 15 studies, the pooled odds ratio was 1.54 (95% CI 1.27 to 1.86, P value < 0.001).”

In the paper

“The majority of trials included in this review collected data before and after interventions on different patients, therefore drop‐out at the patient level was not an issue for these trials.”

In the paper

“Also, it is not possible to determine from the studies reviewed which methods of identifying determinants and tailoring interventions to account for them should be selected.”

In the paper

“26 were included in the previous version (Baker 2010)”

What the sources say

• Not checked yetcites Baker 2010 source

In the paper

“Whether adjustment was made for local factors New In some studies, adjustments were made at the level of the cluster (clinical team, hospital), and these adjustments could potentially improve the intervention effect Add”

In the paper

“We excluded three studies from this update that had been included in the previous version of the review because we assessed them as no longer meeting our criteria for tailoring.”

In the paper

“The studies employed various interventions to improve professional practice”

In the paper

“Outcome: Healthcare outcomes Cluster‐RCTs Insufficient data in the included studies Outcome: Costs Cluster‐RCTs Insufficient data in the included studies Outcome: Adverse events Cluster‐RCTs Insufficient data in the included studies”

In the paper

“In the included studies, tailoring was undertaken in different ways and agreement on which methods should be used appeared to be absent.”

In the paper

“the methods of tailoring are not yet well developed and are not described in detail in published studies.”

In the paper

“It was possible to include 32 trials in this update”

In the paper

“New searches performed to December 2014 and nine new studies identified”

• Also stated in: § What's new · plain

  “We excluded three studies from the previous version of the review and added nine studies in this update, giving 32 studies in total.”

In the paper

“New search for studies and content updated (no change to conclusions)”

In the paper

“We excluded three studies from the previous version of the review in this update, and added nine studies, giving 32 studies in total.”

In the paper

“Although there are a number of reviews in specific clinical fields (Chaillet 2006; Kroenke 2000), which have discussed the possibility that tailored strategies might be more effective than strategies selected without taking account of determinants, these reviews did not address the effect or costs of tailored interventions specifically.”

What the sources say

• Not checked yetcites Chaillet 2006 source
• Not checked yetcites Kroenke 2000 source

In the paper

“which concluded that tailored interventions were more likely to improve professional practice than no intervention or dissemination of guidelines or educational materials alone.”

In the paper

“Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice).”

• Also stated in: § Background · hedged

  “determinants are believed to influence the success of improvement strategies.”

In the paper

“there can be delays before the findings of research are widely adopted”

What the sources say

• Not checked yetcites Grol 2005
• Not checked yetcites Oxman 1995

In the paper

“it would appear reasonable to expect performance to improve”

In the paper

“This unexpected finding may be due to imprecision, chance, the small number of studies, and other unexplained factors.”

In the paper

“Two review authors independently classified the intensity of the methods used to identify determinants using the following three categories”

In the paper

“It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.”

• Also stated in: § Plain language summary · plain

  “There is insufficient evidence on the most effective approaches to tailoring, including how determinants should be identified, how decisions should be made on which determinants are most important to address, and how interventions should be selected to account for the important determinants.”

In the paper

“In our analyses, we used meta‐regression in order to be able to account for differences between control and intervention groups at study baselines.”

In the paper

“We applied no language restrictions in the searches or inclusion of studies.”

In the paper

“We conducted a sensitive search of major biomedical databases and trial registries (see Search methods for identification of studies).”

In the paper

“Two review authors independently extracted the data from included studies by using a revised version of the data extraction form used in the previous version of the review (Baker 2010).”

What the sources say

• Not checked yetcites Baker 2010 source

In the paper

“Two review authors assessed the risk of bias of the included studies using the approach set out in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).”

What the sources say

• Not checked yetcites Higgins 2011

In the paper

“Since the studies were of interventions designed to implement appropriate clinical practice, adverse effects may have been unlikely, although it is possible that the implementation interventions could have unintended effects.”

In the paper

“Two review authors independently assessed studies for inclusion.”

In the paper

“For the 15 studies included in the meta‐regression, we combined the estimated odds ratios for each study (adjusted for clustering) using meta‐regression techniques, whereby the baseline odds ratios were included as a covariate to adjust for any baseline differences between the intervention and control groups (Sutton 2000).”

What the sources say

• Not checked yetcites Sutton 2000

In the paper

“Two independent review authors classified the extent to which the tailored intervention was adjusted to account for local factors using the following two categories”

In the paper

“Bosch and colleagues undertook a qualitative analysis of 20 quality improvement studies reporting investigation of determinants (Bosch 2007).”

What the sources say

• Not checked yetcites Bosch 2007 source

In the paper

“We assessed heterogeneity for all meta‐regression models using the I² residual statistic (Higgins 2003), which represents the proportion of residual between‐study variation due to heterogeneity, as opposed to sampling variability.”

What the sources say

• Not checked yetcites Higgins 2003 source

In the paper

“There is no equivalent of forest or funnel plots for meta‐regression analyses and reliance on only follow‐up results to produce such plots would have provided misleading information.”

In the paper

“but in many studies the reasons for believing a particular strategy would address a particular determinant were not explained.”

What the sources say

• Not checked yetcites Bosch 2007 source

In the paper

“In the meta‐regression analyses, we carried out sensitivity analyses assuming a larger clustering effect than had been accounted for in the standard analyses, by using higher ICC estimates (i.e. the reported upper quartile range values) taken from Campbell (Campbell 2005).”

What the sources say

• Not checked yetcites Campbell 2005 source

In the paper

“Campbell et al extracted 220 ICCs from 21 data sets and reported the results separately for both primary and secondary care settings.”

What the sources say

• Not checked yetcites Campbell 2005 source

In the paper

“Consequently, there may be additional evidence on the effectiveness of tailoring or on how it can be undertaken most effectively.”

In the paper

“Tailored implementation can be effective, but the effect is variable and tends to be small to moderate.”

• Also stated in: § Plain language summary · plain

  “The findings continue to indicate that tailored interventions can change professional practice, although they are not always effective and, when they are, the effect is small to moderate.”

• Also stated in: § Discussion · plain

  “Tailored implementation can be effective, but the effect is variable and tends to be small to moderate.”

In the paper

“Once determinants have been identified and those to be addressed have been chosen, strategies to address them have to be selected, but this process may be undertaken in different ways (Wensing 2014).”

What the sources say

• Not checked yetcites Wensing 2014 source

In the paper

“it is possible that use of such interventions (for example, audit with feedback, educational outreach) would have improved professional practice whether or not tailoring had been undertaken.”

In the paper

“if several methods are used together, a large number of determinants may be identified (Krause 2014a)”

What the sources say

• Not checked yetcites Krause 2014a

In the paper

“Risk of bias overall Unclear risk 5 criteria unclear risk”

In the paper

“Outcome: Implementation of recommended practice, e.g. clinical practice guideline recommendations 17 (7 studies included in meta‐regression) Cluster‐RCTs (4) Borderline risk of bias (‐0.5) Inconsistency between studies, and between outcomes within studies (‐0.5) No serious indirectness No serious imprecision None 3”

In the paper

“Using a complex search, including a sensitive RCT filter, in the key electronic databases should have identified the majority of relevant, published trials.”

In the paper

“Risk of bias overall Unclear risk 4 criteria unclear risk, including randomisation and allocation concealment”

What the sources say

• Not checked yetcites Foy 2004 source

In the paper

“Risk of bias overall Unclear risk 5 criteria unclear risk”

In the paper

“Whether adjustment was made for local factors New In some studies, adjustments were made at the level of the cluster (clinical team, hospital), and these adjustments could potentially improve the intervention effect Add”

In the paper

“Determinants may be classified in different ways (Légaré 2009).”

What the sources say

• Not checked yetcites Légaré 2009

In the paper

“Use of a theory when developing an intervention In analysis Theories of human behaviour potentially help explain why a determinant affects practice and indicate which interventions are most likely to address the determinants Keep”

In the paper

“We pooled a relatively wide variety of outcomes in the meta‐regression analysis, although in all studies the study outcomes related to processes of care, and the studies all addressed the same question about the effectiveness of tailored interventions.”

In the paper

“Since the identification of determinants and tailoring of strategies involve additional steps beyond the application of a particular strategy, such as education alone, the economic costs of tailoring may be higher than several other interventions.”

In the paper

“Risk of bias overall Unclear risk Allocation concealment”

What the sources say

• Not checked yetcites Flottorp 2002 source

In the paper

“Risk of bias overall Unclear risk 5 criteria unclear risk”

What the sources say

• Not checked yetcites Callahan 1994 source

In the paper

“Risk of bias overall Unclear risk 4 criteria unclear risk”

What the sources say

• Not checked yetcites Engers 2005 source

In the paper

“However, this is more likely to be a source of bias for reviews in which interrupted time series and controlled before‐after studies are included, since in comparison with these types of studies, randomised trials are more likely to be identified through electronic database searches.”

In the paper

“Conversely, they may be lower through enabling the more expensive elements of interventions to be reserved for situations when they are likely to be effective.”

In the paper

“In the meta‐regression analysis, the outcomes included were either those reported as the primary outcome or, when this was not possible, we selected the most clinically relevant measure and therefore the introduction of bias is unlikely.”

In the paper

“Determinants may be investigated by various methods”

What the sources say

• Not checked yetcites Krause 2014a

In the paper

“Contamination Low risk Randomisation at nursing home level”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Allocation concealment (selection bias) Unclear risk Information not provided”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk 2 intervention nursing homes withdrew during the study, and 1 control home was excluded as no influenza vaccination was offered during the study period”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk Data collection done by medical abstractors but it is not clear if they were blinded”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk Follow‐up of 85% of patients achieved”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Random sequence generation (selection bias) Unclear risk A randomised block design was used, but the method for generating the randomisation sequence was not described”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Risk of bias overall Unclear risk 1 high risk and 5 unclear risk criteria”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Low risk The vaccinating professional recorded the vaccination on a website”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Random sequence generation (selection bias) Unclear risk Details not reported”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Contamination Unclear risk Practices were randomised”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Baseline outcomes Unclear risk The baseline outcomes were similar, except for onset to drug treatment within 180 minutes; not clear if this was adjusted for”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk No loss to follow‐up after randomisation”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Allocation concealment (selection bias) High risk Allocation was not undertaken independently”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Unclear risk It is not clear why the mean number of charts reviewed is lower than the 45 planned for; some charts were not available at post intervention data collection”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Baseline characteristics Low risk Baseline characteristics comparable”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Risk of bias overall Unclear risk 4 unclear risk criteria”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk Data were collected from patient charts and it is not clear whether the data collectors were blinded”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Allocation concealment (selection bias) Unclear risk Details not clear.”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Risk of bias overall Unclear risk 1 high risk, 5 unclear risk criteria”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk Only 1 hospital withdrew after randomisation”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Baseline characteristics Low risk Patient characteristics were similar”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Baseline characteristics Unclear risk Baseline patient characteristics comparable other than age, BP, and smoking prevalence in 1 group, but not clear whether adjusted for”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Baseline outcomes Low risk Baseline outcomes were similar”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Contamination Low risk Hospitals randomised”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Other bias Low risk Low likelihood of contamination; baseline characteristics of patients similar”

What the sources say

• Not checked yetcites Lakshminarayan 2010 source

In the paper

“Contamination Low risk The hospital was the unit of randomisation”

What the sources say

• Not checked yetcites Leviton 1999 source

In the paper

“Contamination Low risk Practice groups randomised”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Other bias Unclear risk Baseline patients' characteristics broadly similar; practices were in a single locality and contamination may have been possible”

What the sources say

• Not checked yetcites Langham 2002

In the paper

“Baseline characteristics Low risk No patient differences between study groups”

What the sources say

• Not checked yetcites Karuza 1995 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk Data were collected from patient records by a research nurse”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Contamination Low risk Pharmacies stratified by geographical location prior to randomisation”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Baseline outcomes Low risk Baseline outcomes comparable”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk Data were collected from all pharmacies in the study”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Other bias Unclear risk There are no baseline performance data; the risk of contamination is unclear”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Baseline characteristics Low risk Characteristics of hospitals and professionals similar at baseline, although there was an uneven distribution of patients with heart failure, but there was adjustment”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Allocation concealment (selection bias) Unclear risk Unable to assess”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Other bias Unclear risk Contamination may have been possible, since geographically related practices were randomised to intervention and control groups. Patient characteristics were similar in both groups”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Contamination Low risk Groups of geographically related practices were randomised”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Risk of bias overall Unclear risk 2 unclear risk criteria (1 allocation concealment)”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Baseline characteristics Unclear risk Baseline characteristics not reported”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Other bias Low risk Comparable baseline characteristics in the study groups; contamination unlikely”

What the sources say

• Not checked yetcites Looijmans 2010 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Random sequence generation (selection bias) Unclear risk Coin toss was used to assign hospitals to intervention or control groups”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Contamination Low risk Randomisation at the level of the district”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Contamination Low risk Randomisation at general practice level”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Baseline outcomes Low risk No differences at baseline”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Risk of bias overall Unclear risk 4 unclear risk, 1 high risk criteria”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Other bias Low risk Baseline characteristics similar; low likelihood of contamination”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Other bias Unclear risk Contamination is unlikely; baseline characteristics of the health centres are not reported”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Allocation concealment (selection bias) Unclear risk Process not reported”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Baseline outcomes Low risk There were baseline differences in some outcomes, but adjusted for”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Baseline characteristics Low risk Intervention and control groups comparable”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Allocation concealment (selection bias) Unclear risk Details not provided”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Random sequence generation (selection bias) Low risk A computer random number function was used”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Baseline characteristics Unclear risk There were no differences in patient characteristics between study groups. No data on clinicians”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk Whether or not the data abstractors were blinded is not reported”

What the sources say

• Not checked yetcites Matchar 2002 source

In the paper

“Risk of bias overall Unclear risk 3 unclear risk criteria”

What the sources say

• Not checked yetcites Murphy 2009 source

In the paper

“Baseline characteristics Unclear risk Baseline characteristics not reported”

What the sources say

• Not checked yetcites Ross‐Degnan 1996 source

In the paper

“Blinding of participants and personnel (performance bias) All outcomes Unclear risk It would not have been possible to blind staff of the study health centres to the intervention group”

What the sources say

• Not checked yetcites Santoso 1996 source

In the paper

“Allocation concealment (selection bias) Low risk Allocation was undertaken by an independent researcher”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Other bias Low risk Low risk of contamination”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Other bias Unclear risk The study took place in a single health maintenance organisation and contamination may be a risk. Baseline adherence was higher than national figures”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk It is not clear whether the data collectors were blind to study groups”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk No practices withdrew”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Baseline characteristics Low risk More physicians in the control group were male. Otherwise, patient and physician characteristics were similar between groups (adjusted for)”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Other bias Low risk Contamination unlikely; baseline characteristics similar”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk Intention‐to‐treat analysis; all included hospitals completed the study”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Baseline characteristics Low risk Patient characteristics comparable except for education and macrovascular complications (adjusted for)”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Random sequence generation (selection bias) Unclear risk No details given”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Other bias Low risk Baseline patient characteristics were similar. Contamination unlikely”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Contamination Low risk Randomisation at the hospital level”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Risk of bias overall Unclear risk 4 unclear risk criteria”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Random sequence generation (selection bias) Unclear risk A random number table was used”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Contamination Low risk Practices were randomised”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Baseline characteristics Low risk Characteristics similar”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Baseline outcomes Unclear risk No baseline data”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Selective reporting (reporting bias) Low risk Appropriate outcomes reported”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Allocation concealment (selection bias) Unclear risk Method not described”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Random sequence generation (selection bias) Unclear risk Method of sequence generation not described”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Risk of bias overall Unclear risk 4 criteria unclear risk”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk There is no information on blinding of data collection”

What the sources say

• Not checked yetcites van Bruggen 2008 source

In the paper

“Contamination Low risk Hospitals randomised”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Allocation concealment (selection bias) Low risk Allocation was undertaken by a data management centre independent of the researchers”

What the sources say

• Not checked yetcites Scott 2013 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Unclear risk It is not clear if the data collectors were blinded”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Risk of bias overall Unclear risk 4 criteria unclear risk”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Baseline characteristics Low risk Patient characteristics were similar”

What the sources say

• Not checked yetcites Soumerai 1998 source

In the paper

“Incomplete outcome data (attrition bias) All outcomes Low risk All hospitals completed the study”

What the sources say

• Not checked yetcites Schouten 2007

In the paper

“Allocation concealment (selection bias) Unclear risk No details given”

What the sources say

• Not checked yetcites Simon 2005 source

In the paper

“Blinding of outcome assessment (detection bias) All outcomes Low risk Symptom questionnaire completed by patients”

What the sources say

• Not checked yetcites Zwarenstein 2007 source

In the paper

“Blinding of outcome assessment (detection bias) 
All outcomes Unclear risk It is not clear if data collectors were blind to study group.”

In the paper

“Baseline outcomes Low risk Baseline outcomes similar”