This review concluded that multiple and linked strategies that targeted different levels of the health care system were most likely to improve access to best practice of primary health care. These conclusions broadly reflect the evidence presented and are likely to be reliable.

To assess the effectiveness of interventions to enhance access to best practice processes of primary health care in three domains (chronic disease management, prevention and episodic care).

Several databases including PubMed, EMBASE, APAIS Health, Cochrane (not specified) and DARE were searched for studies in English from January 1999 and June 2009. Search terms were reported. Non peer-reviewed studies such as government reports were searched via relevant organisations, websites or in consultation with key stakeholders. Reference lists of relevant publications and targeted journals were screened for further studies.

Studies that evaluated an intervention to improve access to one of the three domains (chronic disease management, prevention and episodic care) of primary health care and measured access in terms of use of relevant recommended processes of care were eligible for inclusion. Eligible studies had to be from Australia, New Zealand, UK, Western Europe, USA or Canada.

Most interventions were found in the domain of prevention, whilst a smaller proportion of interventions were found in the domains of episode care or chronic disease management. Most studies used a single strategy, whist the remaining studies used a combination of two or more strategies. The evaluated strategies were classified into five subgroups: patient support, practice reorganisation, financial incentives, workforce development and provision of new services. These strategies targeted both health providers and patients. The main reported outcomes were changes in service use, provision of care processes (such as evidence based screening), enhanced follow-up or continuity of care, use of alternate services and reduced waiting times. Most studies were conducted in Australia, USA and UK.

The authors did not state how many reviewers assessed studies for inclusion.

The quality of studies was assessed using the Quality Assessment Tool for Quantitative Studies being developed from the Effective Public Health Practice Project. The tool included the following criteria: selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity and analysis. Study quality was classified as low, medium or high.

One reviewer performed quality assessment.

Data were extracted on the number of studies reporting positive changes in access to best practice process of primary health care.

One reviewer performed data extraction and a second reviewer checked it for completeness and accuracy. Any disagreements were resolved by consensus within the team.

The studies were combined in a narrative synthesis, grouped by different domains of primary health care.

Seventy-five studies were included in the review; 45 studies of prevention, 19 studies of episodic care and 11 studies of chronic disease management. The total number of participants was not reported. Twenty-three studies were judged as high quality, 46 studies as medium quality and six studies as low quality. All high quality studies were from the prevention domain, with 10 studies being randomised controlled trials and 13 studies being longitudinal studies based on the extract of testing records from the large population-based Pap testing registers.

Of the 75 studies, 54 reported a positive outcome of the strategy to enhance access to best practice processes of primary health care, with a statistically significant increase in use of services or processes of care; studies using a combination of strategies were more likely to report a positive outcome.

Two studies reported that public education campaigns for patients had a beneficial role for enhancing access to preventive care, with social media promoting services and increasing community expectations for screening programmes of Pap testing and increase screening rates.

Fifteen out of nineteen studies in the domain of episodic care, which evaluated new services or booking systems to improve access to same day or after-hours care, reported a positive change in access to best practice.

The findings suggested that multiple and linked strategies that targeted different levels of the health care system were most likely to improve access to best practice of primary health care.

The review question was clear and supported by appropriate broad inclusion criteria. Several relevant databases were searched. Efforts were made to find both published and unpublished studies with an attempt to reduce potential for publication bias. Only studies in English were included in the search, which may have introduced language bias. Attempts were made to minimise errors and biases during data extraction; however, only one reviewer performed quality assessment, so reviewer errors and biases during this process cannot be ruled out. It was unclear whether steps were made to minimise errors and biases during study selection. The quality of studies was assessed using appropriate criteria and most of studies were of medium to high quality. The level of diversity between studies was appropriately assessed. Given this diversity of included studies, a narrative synthesis was appropriately employed.

The authors' cautious conclusions broadly reflect the evidence presented and are likely to be reliable.

Practice: The authors stated that the proposed changes in the structure of primary health care in Australia may provide opportunities to investigate factors that influence access to best practice of primary health care and to develop and implement effective, evidence based strategies.

Research: The authors stated that further studies were required to identify the elements of complex interventions that were effective in improving access to primary health care.

Australian Government Department of Health and Ageing.

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.