Home > DARE Reviews > Meta-analysis: effect of interactive...

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists

R Foy, S Hempel, L Rubenstein, M Suttorp, M Seelig, R Shanman, and PG Shekelle.

Review published: 2010.

CRD summary

The authors found a potential role for interactive communication for improving the effectiveness of collaboration between primary care physicians and specialists in the clinical areas of psychiatry and diabetes care. The review was largely well-conducted, and the authors' cautious conclusion is likely to be reliable.

Authors' objectives

To evaluate the effectiveness of interactive communication between collaborating primary care physicians and specialists on outcomes relating to patients in ambulatory care.

Searching

PubMed, PsycINFO, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, DARE and Web of Science were searched from inception to June 2008 without language restriction. Search terms were reported. References lists of relevant articles and reviews were scanned for additional studies.

Study selection

Randomised controlled trials (RCTs) and non-RCTs, controlled and uncontrolled before-after studies, and time-series analyses that focused on planned collaboration directly between primary care physicians and specialists, working as individuals or clinical teams, and using any method of interactive communication, were eligible for inclusion in the review. Studies had to be conducted in outpatient and community primary care settings, and in countries where health care systems were generalisable to the United States context. Professionals specialising in treating patients with diabetes, psychiatric conditions, or cancer (including palliative care) were the collaborative groups of interest. Studies of collaborative arrangements where less than 75% of professionals belonged to these clinical groups were excluded.

Outcomes of interest were selected from the included studies by two independent and blinded reviewers. The selected patient outcome measures were haemoglobin A1c in studies of diabetes, the Centre for Epidemiologic Studies Depression Scale, a version of the Symptom Check List, or the Hamilton Depression Scale in studies of psychiatric conditions.

Most included studies related to psychiatric patients; there were no studies of cancer. Approximately half of the studies were conducted in the United States or the United Kingdom. Included interventions comprised face-to-face meetings, paper or electronic letters or notes, telephone discussions and video-conferencing, with some studies combining various methods.

Two reviewers independently selected studies for inclusion in the review. Disagreements were resolved by discussion, and by reference to other reviewers.

Assessment of study quality

A seven-item checklist was used to score the internal validity of studies covering: randomisation; allocation concealment; sample size calculation; blinding; reliability of outcome measures; completeness of follow-up; and appropriateness of analysis. A six-item checklist was used to score: external validity; covering representativeness of study population; replicability and sustainability of the intervention; appropriateness of outcome measures; long-term follow-up; and process evaluation. Studies were scored according to the number of criteria met.

The authors did not state how many reviewers performed the quality assessment.

Data extraction

Data were extracted to enable the calculation of standardised mean differences (SMDs) and 95% confidence intervals (CI). Data were also extracted on core features of the interventions, and any co-interventions.

One reviewer extracted the data, and this was checked by a second reviewer. Disagreements were resolved by discussion, and by reference to other reviewers.

Methods of synthesis

Standardised mean differences and 95% confidence intervals were pooled in a random-effects meta-analysis (DerSimonian and Laird), and stratified according to type of collaborating specialist and presence of randomisation. Statistical heterogeneity was assessed using the I2 statistic (75% indicating very high heterogeneity). Sensitivity analyses were conducted to explore heterogeneity by removing outliers from the meta-analysis, and to adjust for clustering effects. Bivariate meta-regression was used to explore the relationship between effect size and intervention features. Publication bias was assessed using the Begg and Egger tests.

Results of the review

Twenty-three studies were included in the review. There were 11 RCTs (2,355 patients), of which six were cluster-randomised; one non-RCT (181 patients); three controlled before-after studies (978 patients); and eight uncontrolled before-after studies (2,415 patients). The internal and external validity of RCTs was considered to be moderate (median internal validity score 5). The median scores for non-RCTs were 3 to 4 for internal validity, and 3 for external validity. Follow-up (where reported) ranged from two months to 36 months (median 9.5 months). There was no consistent evidence of publication bias.

In studies of patients with psychiatric conditions, the pooled analysis of 11 RCTs showed that interactive communication produced small to moderate, but statistically significant, improvements in patient depression outcomes (SMD -0.41, 95% CI -0.73 to -0.10). A further seven non-randomised studies showed a similar improvement in patient depression outcomes (SMD -0.47, 95% CI -0.84 to -0.09). In studies involving patients with diabetes, the pooled analysis of five non-randomised studies showed that interactive communication resulted in moderate, statistically significant improvements in haemoglobin A1c (SMD -0.64, 95% CI -0.93 to -0.34). There was high heterogeneity across all analyses (I2=84.9% to 91.7%).

Sensitivity analysis did not materially alter the main findings. Meta-regression analysis showed that interventions that included measures to enhance the quality of information exchange produced larger effects on patient outcomes than those that did not (SMD -0.84 versus -0.27). Effect sizes were similar in integrated and non-integrated health care systems.

Authors' conclusions

A potential role was found for interactive communication for improving the effectiveness of collaboration between primary care physicians and specialists.

CRD commentary

The review question was clear and inclusion criteria were stated for all aspects, except outcomes. Outcome measures were chosen from included studies in a manner which suggested that selection bias was minimised. The search strategy included several relevant sources and attempts were made to address language bias. It was not clear to what extent unpublished material was sought, so relevant studies may have been missed. It appeared that appropriate validity assessment criteria were chosen for the included study designs. The selection of studies was carried out with sufficient attempts to minimise reviewer error and bias; this was partially the case in the process of data extraction, but it was not clear how the validity assessment was performed.

Study characteristics were provided in detail, and the chosen method of synthesis appeared to be appropriate in the presence of high heterogeneity which was explored. The authors drew attention to limitations of the review, including narrow generalisability and inability to distinguish the effective elements of multifaceted interventions.

The review was largely well-conducted, and the authors' cautious conclusion is likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that investments to promote interactive communication between primary care physicians and specialists may offer equal or more benefit than many clinical interventions.

Research: The authors stated that further studies are needed to explore the key variants necessary for the development of structured interaction between primary care physicians and specialists across other clinical disciplines.

Funding

RAND Health's Comprehensive Assessment of Reform Options Initiative; the Veterans Affairs Centre for the Study of Provider Behaviour; The Commonwealth Fund; The Health Foundation.

Bibliographic details

Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Annals of Internal Medicine 2010; 152(4): 247-258. [PubMed: 20157139]

Indexing Status

Subject indexing assigned by CRD

MeSH

Communication; Continuity of Patient Care; Diabetes Mellitus; Humans; Interdisciplinary Communication; Interprofessional Relations; Neoplasms; Physicians, Family; Primary Health Care; Psychiatry; Referral and Consultation

AccessionNumber

12010001017

Database entry date

24/02/2010

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.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20157139

PubMed Health Blog...

read all...

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...