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Consumer Intervention: Improving quality


Strategies to improve the total package, coordination or integration of care delivered. Interventions can involve substitution or expansion of one type of care, such as interventions that aim to overcome system barriers to medicines use, including access and financial barriers.


There is some evidence that interventions to change the integration of care may improve adherence and other outcomes related to medicines use, however the results are generally mixed. Specifically there is sufficient evidence that continuous labour support reduces use of analgesia or anaesthesia, increases spontaneous vaginal birth without increasing negative rating of birth experiences, labour length, postpartum report of severe labour pain or number of infants with low 5 minute Apgar score - it is generally effective. However such continuous support does not appear to reduce synthetic oxytocin use during labour, maternal perineal trauma, neonatal admission to the special care nursery or prolonged neonatal hospital stays.

There is also some evidence that pharmacist-delivered services (medicines review or expanded roles) targeting patients may reduce the total number of medicines prescribed and improve clinical outcomes including mortality, although results are mixed. The effects of care delivery including self-management strategies or service organisation interventions for epilepsy, ischaemic heart disease or hypertension were inconsistent or unable to be determined.
There is some evidence that lay health worker interventions, patient financial interventions, tailored reminders (letter postcard or phone call); participants reminder and recall; home visits plus vaccination; free vaccination offers; facilitators working with physicians and financial incentives to physicians are effective for immunisation or smoking cessation treatment uptake.

For childhood asthma, there is some evidence that home-based education reduces exacerbations leading to hospitalisation when compared to usual care. There is insufficient evidence that home-based intervention reduces exacerbations requiring oral corticosteroids or emergency department visits, symptoms or caregiver/child quality of life. There is insufficient evidence that home-based education for asthma, when compared to a less intensive education intervention, improves symptoms or quality of life or reduces exacerbations requiring oral corticosteroids, emergency department visits or hospitalisation.
However there is insufficient evidence to decide the effects of physician reminders alone for immunisation coverage, interventions to improve coverage of child immunization in low- and middle-income countries or professional financial incentives for smoking cessation. There is also insufficient evidence to determine whether changing health care setting, supporting hospital discharge planning or cancer clinic orientation for patients and carers are effective in improving medicines use and related outcomes.

For medicines pricing policies: there is some evidence that reference pricing increases the use of reference medicines and decreases the use of cost share medicines and total medicines costs; but there is also some evidence that it has mixed effects on healthcare use. There is insufficient evidence to decide on the effects of reference pricing on patient expenditure or of index pricing on medicines use outcomes.

For cap and co-payment policies the evidence is mixed for medicines use and costs. There is some evidence that fixed co-payments, with or without a cap, decrease overall prescription medicines use, but have mixed effects on patient medicines expenditure and cost per prescription - the results are mixed; there is insufficient evidence to determine effects on essential medicines use. There is some evidence that caps, fixed co-insurance with ceiling interventions and changes in tiered co-payments interventions may be effective to decrease overall medicines use, but may also have variable effects on discretionary and essential medicines use, as well as health care use and consumer expenditure - the results are mixed. There is insufficient evidence to determine the effects of fixed (income-based) interventions or fixed co-payment plus co-insurance, with or without ceiling interventions, on overall, essential or discretionary medicines use.

Summary of Overall Findings from Reviews

Summary of Findings Related to Prescribing

37 reviews focusing on improving the quality of care in relation to medicines use were identified, 18 of which were high quality.

One large review (Haynes 2008) looking across health conditions evaluated diverse interventions, including strategies to improve care delivery and to overcome system barriers, reported that less than half of interventions improved adherence and a minority improved clinical outcomes.

Primary care service organisation interventions for ischaemic heart disease significantly improved the majority of blood pressure outcomes but did not improve cholesterol levels or lipid-lowering, beta blocker, ACE inhibitor or anti-platelet clinical medicine prescribing outcomes (Buckley 2010).

Continuous labour support significantly reduced any analgesia (including regional analgesia) or anaesthesia use as well as negative rating of birth experiences, labour length and numbers of instrumental vaginal and caesarean births as well as increased spontaneous vaginal birth without increasing postpartum reports of severe labour pain. The number of infants with low 5 minute Apgar scores was also significantly reduced, however, the use of synthetic oxytocin during labour and perineal trauma were not significantly changed nor were prolonged neonatal hospital stays and special care nursery admissions (Hodnett 2011).
Two further cross-disease reviews assessed altered roles for health professionals. In Royal (2008), pharmacist-led medicines review decreased adverse events and mortality, although results were mixed; and there were no consistent effects on service use outcomes, nor of interventions delivered by professionals other than pharmacists. Pharmacist-delivered services directed at patients reduced total number of medicines prescribed, however effects on clinical outcomes and mortality were mixed and there was insufficient evidence to determine the effect on adverse reactions and adherence (Nkansah 2010). There is insufficient evidence to determine the effect of interventions delivered by pharmacists that are directed at health professionals.

Lewin (2010) showed that lay health worker interventions to improve immunisation uptake were effective. Another review of coverage strategies found that participant reminders and recall, particularly tailored reminders such as letters, postcards or phone calls; home visits plus vaccination; the offer of free vaccination; facilitators working with physicians and financial incentives to physicians may significantly increase community immunisation demand. However, the effects of other vaccination interventions were unclear (Thomas 2010). The effectiveness of home-based education for asthma was also unclear; while it may reduce exacerbations leading to hospitalisation, there was no evidence that it reduced other types of patient outcomes (e.g. exacerbations leading to emergency department visits) (Welsh 2011).

In low and middle income countries, information campaigns, home visits, evidence-based discussion with community groups, or facility based education alone or in combination with redesigned immunisation may improve immunisation coverage; however, there was limited evidence around monetary incentives and provider oriented training interventions alone or in combination with other health system interventions (Oyo-Ita 2011). Full patient financial incentives increased the uptake of smoking cessation treatments, but partial patient financial incentives had mixed effects and there was insufficient evidence to decide on the effects of professional financial incentives (Reda 2009).

Other disease-specific reviews focusing on strategies to improve quality, including specialist nurses and specialist units for epilepsy (Bradley 2008), epilepsy care delivery or self management interventions for children with epilepsy and their families (Lindsay 2010), worksite interventions, home visits, and a pharmaceutical care model for hypertension (Schroeder 2004), found mixed results for adherence, knowledge and clinical outcomes. Changing the setting of care gave mixed results in children with diabetes (Clar 2007). Results were mixed with regard to the effect of pharmacy discharge planning on medicines errors, adherence and knowledge. In addition, there was insufficient evidence to determine the effect of either pharmacy or nurse discharge planning interventions or cancer clinic orientation on other outcomes (Shepperd 2010, Chan 2011).

Two further reviews assessed the effects of medicines pricing policies which indirectly influence consumers' medicines use through different pricing structures and/or by altering the financial impact of medicines use (Aaserud 2006, Austvoll-Dahlgren 2008). Aaserud (2006) reported that reference pricing policies significantly increased the use of the specific reference medicines, without affecting total reference medicines use, or use of medicines other than those in the reference group. Reference pricing decreased the use of cost share medicines and decreased total expenditure, but increased patients' share of total medicines expenditure and had mixed effects on health care use.

Austvoll-Dahlgren (2008) reported similar outcomes for the effects of different cap and copayment policies. Caps, copayments, co-insurance with ceiling strategies and changes in tiered co-payments, alone or in different combinations, significantly decreased plan overall medicines expenditure and overall prescription medicines use. However, these policies had mixed effects on discretionary and essential medicines usage, patterns of health care use and consumer medicines expenditure. The effects of fixed co-payments, fixed co-payments plus co-insurance with or without ceilings, or of index pricing policies were unable to be determined.

Reviews listed as "Summary Pending" will be analyzed, summarized and reported at a later date.

The findings will then be incorporated in the overall evidence summaries of the interventions they address.

Reviews Addressing This Intervention Quality Assessment Tool:
AMSTAR Score (of 11 points)
Welsh EJ, Hasan M, Li P. Home-based educational interventions for children with asthma. Cochrane Database of Systematic Reviews 2011 10:CD008469. 11 (High)
Aaserud M, Dahlgren AT, Kosters JP, Oxman AD, Ramsay C, Sturm H. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. Cochrane Database of Systematic Reviews 2006 2:CD005979. 10 (High)
Austvoll-Dahlgren A, Aaserud M, Vist G, Ramsay C, Oxman AD, Sturm H, Kosters JP, Vernby A. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database of Systematic Reviews 2008 1:CD007017. 10 (High)
Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008 2:CD000011. 10 (High)
Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk B, Odgaard-Jensen J, Johansen M, Aja G, Zwarenstein M, Scheel I. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010 3:CD004015. 10 (High)
Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database of Systematic Reviews 2004 2:CD004804. 10 (High)
Thomas RE, Russell M, Lorenzetti D. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database of Systematic Reviews 2010 9:CD005188. 10 (High)
Bradley PM, Lindsay B. Care delivery and self-management strategies for adults with epilepsy. Cochrane Database of Systematic Reviews 2008 1:CD006244. 9 (High)
Chan RJ, Webster J, Marquart L. Information interventions for orienting patients and their carers to cancer care facilities. Cochrane Database of Systematic Reviews 2011 12:CD008273. 9 (High)
Clar C, Waugh N, Thomas S. Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus. Cochrane Database of Systematic Reviews 2007 2:CD004099. 9 (High)
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011 2:CD003766. 9 (High)
Lindsay B, Bradley PM. Care delivery and self-management strategies for children with epilepsy. Cochrane Database of Systematic Reviews 2010 12:CD006245. 9 (High)
Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond C, Bero L. Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database of Systematic Reviews 2010 7:CD000336. 9 (High)
Reda AA, Kaper J, Fikrelter H, Severens JL, van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database of Systematic Reviews 2009 2:CD004305. 9 (High)
Shepperd S, McClaran J, Phillips C, Lannin N, Clemson L, McCluskey A, Cameron I, Barras S. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2010 1:CD000313. 9 (High)
Buckley B, Byrne M, Smith S. Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database of Systematic Reviews 2010 3:CD006772. 8 (High)
Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countries. Cochrane Database of Systematic Reviews 2011 7:CD008145. 8 (High)
Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Quality & Safety in Health Care 2006 15 (1):23-31. 8 (High)
Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, Coker-Schwimmer EJ, Rosen DL, Sista P, Lohr KN. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Annals of Internal Medicine 2012 157 (11):785-795. 8
Summary Pending
Bayoumi I, Howard M, Holbrook A, Schabort I. Interventions to improve medication reconciliation in primary care. The Annals of Pharmacotherapy 2009 43 (10):1667-75. 7 (Medium)
Roughead EE, Semple SJ, Vitry AI. Pharmaceutical care services: A systematic review of published studies, 1990 to 2003, examining effectiveness in improving patient outcomes. International Journal of Pharmacy Practice 2005 13 (1):53-70. 7 (Medium)
Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Annals of Internal Medicine 2002 136 (9):641-51. 7 (Medium)
Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ 1997 315 (7110):703-7. 6 (Medium)
Haywood CJ, Beach M, Lanzkron S, Strouse J, Wilson R, Park H, Witkop C, Bass E, Segal J. A systematic review of barriers and interventions to improve appropriate use of therapies for sickle cell disease. Journal of the National Medical Association 2009 101 (10):1022-33. 6 (Medium)
Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. British Journal of Clinical Pharmacology 2008 65 (3):303-16. 6 (Medium)
Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Archives of Internal Medicine 2008 168 (7):687-94. 6 (Medium)
Maio V, Pizzi L, Roumm AR, Clarke J, Goldfarb NI, Nash DB, Chess D. Pharmacy utilization and the Medicare Modernization Act. Milbank Quarterly 2005 83 (1):101-30. 6 (Medium)
Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Medical Care 2008 46 (8):847-62. 6 (Medium)
van Eijken M, Tsang S, Wensing M, de Smet PA, Grol RP. Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature. Drugs & Aging 2003 20 (3):229-40. 6 (Medium)
Castelino R, Bajorek B, Chen T. Targeting suboptimal prescribing in the elderly: a review of the impact of pharmacy services. The Annals of Pharmacotherapy 2009 43 (6):1096-106. 5 (Medium)
De Bleser L, Matteson M, Dobbels F, Russell C, De Geest S. Interventions to improve medication-adherence after transplantation: a systematic review. Transplant International 2009 22 (8):780-97. 5 (Medium)
Lummis H, Sketris I, Veldhuyzen van ZS. Systematic review of the use of patients' own medications in acute care institutions. Journal of Clinical Pharmacy and Therapeutics 2006 31 (6):541-63. 5 (Medium)
Mbuba CK, Ngugi AK, Newton CR, Carter JA. The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies. Epilepsia 2008 49 (9):1491-503. 5 (Medium)
Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention: a meta-analysis. Obstetrics and Gynecology 2007 110 (6):1379-88. 5 (Medium)
Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expectations 2004 7 (3):235-45. 5 (Medium)
Vergouwen AC, Bakker A, Katon WJ, Verheij TJ, Koerselman F. Improving adherence to antidepressants: a systematic review of interventions. The Journal of clinical psychiatry 2003 64 (12):1415-20. 5 (Medium)
Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression. The British Journal of Psychiatry 2006 189:484-93. 4 (Medium)
Odegard PS, Capoccia K. Medication taking and diabetes: a systematic review of the literature. The Diabetes Educator 2007 33 (6):1014-29. 4 (Medium)
Saberi P, Dong BJ, Johnson MO, Greenblatt RM, Cocohoba JM. The impact of HIV clinical pharmacists on HIV treatment outcomes: a systematic review. Patient preference & adherence 2012 6:297-322. 4
Summary Pending
Altowaijri A, Phillips CJ, Fitzsimmons D. A systematic review of the clinical and economic effectiveness of clinical pharmacist intervention in secondary prevention of cardiovascular disease. Journal of Managed Care Pharmacy 2013 19 (5):408-416. Summary Pending
Chersich MF, Luchters S, Ntaganira I, Gerbase A, Lo YR, Scorgie F, Steen R. Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. Journal of the International AIDS Society 2013 16 (1):17980. Summary Pending
Huang Y, Wei X, Wu T, Chen R, Guo A. Collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysis. BMC Psychiatry 2013 13 (260). Summary Pending
Laba TL, Bleasel J, Brien JA, Cass A, Howard K, Peiris D, Redfern J, Salam A, Usherwood T, Jan S. Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: a systematic review. International Journal of Cardiology 2013 167 (6):2430-2440. Summary Pending
Macdonald L, Cairns G, Angus K, de AM. Promotional communications for influenza vaccination: a systematic review. Journal of Health Communication 2013 18 (12):1523-1549. Summary Pending
Mdege ND, Chindove S, Ali S. The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review. Health Policy & Planning 2013 28 (3):223-236. Summary Pending
Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 2012 345:e5205. Summary Pending
Suthar AB, Hoos D, Beqiri A, Lorenz-Dehne K, McClure C, Duncombe C. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. Bulletin of the World Health Organization 2013 91 (1):46-56. Summary Pending
Tudor CL, van Velthoven MH, Brusamento S, Elmoniry H, Car J, Majeed A, Tugwell P, Welch V, Marusic A, Atun R. Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review. PLoS ONE [Electronic Resource] 2012 7 (4):e35268. Summary Pending