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Review of computer-generated outpatient health behavior interventions: clinical encounters 'in absentia' |
Revere D, Dunbar P J |
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Authors' objectives To evaluate the evidence of the effectiveness of computer-generated health behaviour interventions, i.e. clinical encounters 'in absentia', as extensions of face-to-face patient care in an ambulatory setting.
Searching The following databases were searched: MEDLINE from 1966 to 1999, HealthSTAR from 1981 to 1999, CINAHL from 1982 to 1999, Current Contents from 1997 to 1999, EMBASE from 1990 to 1999, Inspec from 1969 to 1999, PsycINFO from 1967 to 1999, and Sociological Abstracts from 1986 to 1999. The Cochrane Collaboration and Web of Science (Science Citation Index Expanded and Social Sciences Index) databases were also searched. To account for grey literature, the authors searched CRISP (Computer Retrieval of Information on Scientific Projects) and Dissertation Abstracts, contacted authors, and conducted targeted Internet searches. LexisNexis was also searched for more popular literature on this subject. Key search terms were: 'compliance', 'patient education', 'preventative health services', 'reminder systems', 'computer', 'telephone', 'pager', 'print communication', 'communication'. Additional terms were: 'adherence', 'motivation', 'education', 'decision making', 'empowerment', 'self-help', 'health behaviour', 'ambulatory care', 'drug monitoring', 'intervention', 'patient reminder', 'tailored reminder', 'targeted reminder', 'tailored intervention', 'targeted intervention', 'computer communication networks', 'computer systems', 'telephone systems', 'paging technology', 'letter', 'postcard', 'counseling' and 'self-assessment'.
Study selection Study designs of evaluations included in the reviewControlled clinical trials and quasi-experimental studies with some evidence of instrument reliability and validity were included.
Specific interventions included in the reviewStudies were included if they considered at least one patient-interactive feedback, reminder, or education intervention intended to influence or improve a stated health behaviour. Specific interventions were categorised as mobile communications, automated telephone communications, or print communications.
Participants included in the reviewThe authors do not state any inclusion or exclusion criteria regarding participants, and little information on participant characteristics was provided in the review.
Outcomes assessed in the reviewStudies were included if they investigated an association between one intervention variable and a health behaviour. The health behaviours included: medication adherence; reduction of blood glucose levels in diabetics; dietetic knowledge and self-care in diabetics; understanding of migraines; improving social support, mood and quality of life; understanding of cancer information; increasing immunisation rate; decreasing cholesterol level and body weight; increasing adherence to behaviour therapy programme; increasing physical activity; smoking cessation; a lowering of fat intake; increasing fruit and vegetable intake; decreasing hospital admissions in asthma; increasing mammogram rate; increasing Pap test rate; and increasing prostate cancer screening rate.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for review, or how many of the reviewers performed the selection.
Assessment of study quality Eligible trials were evaluated using a 10-point rating system. Sampling, randomisation aspects, and the presence of a control group were weighted most heavily (totalling 7 points). The minimum score was set at 5 for inclusion. Ratings were based on recommendations from the literature (See Other Publications of Related Interest nos. 1-2). The authors do not state how the papers were assessed for validity, or how many of the reviewers performed the validity assessment.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction. Data were extracted on: author(s), year of publication, methods, health behaviour, the number of participants, and results.
Methods of synthesis How were the studies combined?A narrative summary was presented due to a lack of homogeneity between studies, which varied in terms of type of intervention and health behaviour investigated.
How were differences between studies investigated?There was no formal test for heterogeneity, but differences between the studies were apparent from the tables, and were discussed in the text of the review.
Results of the review Forty-six studies were eligible for inclusion, 9 of which received validity scores below 5 and were excluded. The remaining 37 studies were included: 28 were randomised controlled trials (RCTs), 4 were described as 'randomised trials', 2 were described as 'controlled trials', 1 was labelled a 'clinical controlled trial', 1 was called a 'clinical trial', and 1 was 'a report of four studies'.
Of the 37 studies, 33 (89.2%) reported improved outcomes and 20 of these (60.6%) were statistically significant. Fourteen studies used targeted interventions and 23 used tailoring. Eleven of the targeted intervention studies (78.6%) reported improved outcomes; 6 of these (54.5%) were statistically significant. Of the 23 tailored intervention studies, 22 (95.7%) reported improved outcomes; 15 of these (68.2%) were statistically significant.
Four studies did not report statistically-significant or improved outcomes. The lack of effect was explained by the use of a limited, non-intensive one-time feedback with no inclusion of psychosocial factors, and the use of similar messages for both control and intervention protocols.
Authors' conclusions The literature indicates that computer-generated health behaviour interventions are effective. While there is evidence that tailored interventions can affect health behaviour change more positively than targeted, personalised or generic interventions, there is little research comparing different tailoring protocols with one another.
CRD commentary The literature search undertaken in this review was thorough, though limited to English language papers. Inclusion and exclusion criteria were applied to the search results, validity was assessed according to a predefined scale, and relevant details of the included studies were given in the data extraction tables. However, it was unclear how many reviewers were involved at the stages of study selection, validity assessment, or data extraction. Though a narrative summary was appropriate given the observed differences between included papers, this summary was brief and simply categorised the included papers in terms of positive and negative results. Validity scores were not taken into account when summarising the papers, and the issue of publication bias was not addressed.
Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors state that future studies need to identify which models are best suited to which health behaviour, whether certain delivery devices are more appropriate for different health behaviours, and how ambulatory care can benefit from patients' use of portable devices.
Bibliographic details Revere D, Dunbar P J. Review of computer-generated outpatient health behavior interventions: clinical encounters 'in absentia'. Journal of the American Medical Informatics Association 2001; 8(1): 62-79 Other publications of related interest 1. Balas EA, Austin SM, Brown GD, Mitchell JA. Quality evaluation of controlled clinical information service trials. Proc Annu Symp Comput Appl Med Care 1993:586-90. 2. Moher D, Hadad AR, Tugwell P. Assessing the quality of randomised controlled trials: current issues and future directions. Int J Technol Assess Health Care 1996;12:195-208.
This additional published commentary may also be of interest. Greene B. Review: computer generated targeted and tailored interventions are modestly effective for improving patient health behaviur. Evid Based Nurs 2001;4:85.
Indexing Status Subject indexing assigned by NLM MeSH Ambulatory Care; Communication; Computer Systems; Exercise; Health Behavior; Humans; Medical Informatics Applications; Models, Psychological; Nutritional Physiological Phenomena; Outcome Assessment (Health Care); Patient Education as Topic /methods; Preventive Health Services; Reminder Systems; Smoking Cessation; Telephone AccessionNumber 12001000362 Date bibliographic record published 31/03/2002 Date abstract record published 31/03/2002 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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