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Table 1 Taxonomy of knowledge translation/quality improvement intervention strategies

From: Seeing the forests and the trees—innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol

Strategy Operational definition
Audit and feedback Summary of clinical performance of health care delivered by an individual clinician or clinic over a specified period, transmitted back to the clinician (e.g., the percentage of a clinician’s patients who achieved a target HbA1c concentration or who underwent dilated-eye examinations with a specified frequency). This strategy is strictly based on clinical data and excludes clinical skills. It can include the number of patients with missing tests and dropouts.
Case management Any system for coordinating diagnosis, treatment, or routine management of patients (e.g., arrangement for referrals, follow-up of test results) by a person or multidisciplinary team in collaboration with, or supplementary to, the primary care clinician. For a randomized controlled trial to qualify, the case management has to have happened more than once. If the study calls the intervention ‘case management,’ we classify it as such.
Clinician education Interventions designed to promote increased understanding of principles guiding clinical care or awareness of specific recommendations for a target disorder or population of patients. Subcategories of clinician education include conferences or workshops, distribution of educational materials (e.g., written, video, or other), and educational outreach visits (i.e., academic detailing). We exclude teaching how to educate patients, counseling skills, motivational interviewing, self-directed learning, and skills related to the intervention (e.g., teaching how to use the website for the randomized controlled trial). We include all health care providers. If the education was part of the individual’s role (e.g., teaching a case manager about diabetes), we do not categorize it as clinician education.
Clinician reminders Paper-based or electronic systems intended to prompt a health professional to recall patient-specific information (e.g., most recent HbA1c value) or to do a specific task (e.g., foot examination). If the strategy was accompanied by a recommendation, we subclassify it as decision support (e.g., giving targets to health care providers). An example is a yellow piece of paper clipped to the medical record with the patient’s information on it. This approach has to have been systematic and part of the implementation of the intervention—we exclude ad hoc clinician reminders.
Continuous quality improvement Interventions explicitly identified as involving the techniques of continuous QI, total quality management, or plan-do-study-act, or any iterative process for assessing quality problems, developing solutions to those problems, testing their effects, and then reassessing the need for further action.
Electronic patient registry General electronic medical record system or electronic tracking system for patients with diabetes. We do not include websites unless patients were tracked over time. To qualify, the system has to have been part of the clinical trial as an intervention (i.e., not pre-existing infrastructure unless used more actively).
Facilitated relay of clinical information Clinical information collected from patients and transmitted to clinicians by means other than the existing medical record. We exclude conventional means of correspondence between clinicians. For example, if the results of routine visits with a pharmacist were sent in a letter to the primary care physician, the use of routine visits with a pharmacist counts as a ‘team change,’ but the intervention does not count as ‘facilitated relay.’ However, if the pharmacist issued structured diaries for patients to record self-monitored glucose values, which were then taken to office visits to review with the primary physician, we count the intervention as facilitated relay. Other examples include electronic or web-based methods through which patients provide self-care data and which clinicians reviewed, as well as point-of-care testing supplying clinicians with immediate HbA1c values. We include passports, referral systems, and dietary information (vs. purely clinical information). In general, the patient should be facilitating the relay. To be included, the information must have gotten to someone with prescribing or ordering ability. For example, if the nurse’s role was expanded to make drug changes, the patient had a portable personal record or ‘diabetes passport,’ and the nurse could directly make a change, we classify the intervention as case management and facilitated relay of clinical information (depending on the study and situation). If the nurse alerted the primary care provider that the patient had run out of drugs, we do not deem this facilitated relay of information because that is a normal part of a nurse’s role.
Financial incentives Interventions with positive or negative financial incentives directed at providers (e.g., linked to adherence to some process of care or achievement of some target outcome). This strategy also includes positive or negative financial incentives directed at patients or system-wide changes in reimbursement (e.g., capitation, prospective payment, or a shift from fee-for-service to salary pay structure).
Patient education Interventions designed to promote greater understanding of a target disorder or to teach specific prevention or treatment strategies, or specific in-person education (e.g., individual or group sessions with diabetes nurse educator, distribution of printed or electronic educational materials). Interventions with education of patients are included only if they also include at least one other strategy related to clinician or organizational change. We do not include occasions of optional education.
Patient reminders Any effort (e.g., postcards or telephone calls) to remind patients about upcoming appointments or important aspects of self care (e.g., reminders to monitor glucose). Interventions with reminders are included only if they also included at least one other strategy related to clinician or organizational change. If the intervention included case management, patient reminders need to be explicit and to represent an extra task as compared to normal case management.
Promotion of self-management Provision of equipment (e.g., home glucose meters) or access to resources (e.g., system for electronically transmitting home glucose measurements and receiving insulin dose changes based on those data) to promote self-management. Interventions promoting self-management are included only if they also include at least one other strategy related to clinician or organizational change. We also include established goals or a print off of a self-management plan (i.e., did not necessarily require equipment or resources). If the study called the intervention promotion of self-management, personalized goal-setting, or action-planning, it is included here. In general, we perceive this as a more active strategy than education of patients.
Team changes Changes to the structure or organization of the primary health care team are defined as present if they meet the following criteria:
1. Adding a team member or shared care—e.g., routine visits with people other than the primary physician (including physician or nurse specialists in diabetic care, pharmacists, nutritionists, podiatrists)
2. Use of multidisciplinary teams—i.e., active participation of professionals from more than one discipline (e.g., medicine, nursing, pharmacy, nutrition) in the primary, routine management of patients
3. Expansion or revision of professional roles (e.g., nurse or pharmacist had a more active role in monitoring of the patient or adjusting drug regimens).
To ensure that every study we classify as case management does not also qualify as a team change, we classify a study of case management also as a study of team changes only if at least two of the above conditions are met. Team changes involve more communication. If the study called the intervention ‘joint visits’ or ‘shared care,’ we classify it as a team change. To qualify, the intervention has to have been done by a health care professional and has to have happened more than once.
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