Promoting best practices for control of respiratory infections

S evere acute respiratory syndrome (SARS) disturbed  the medical community’s complacency about control of respiratory infections. Severe acute respiratory  syndrome  disproportionately  affected  health  care  workers and innocent bystander patients1,2 and revealed  the  potential  for  spread  of  respiratory  infection  in  primary  care  offices.3   More  recently,  occurrences  of  avian  influenza in Asia, Europe, and North America with occasional  spread  to  humans  has  increased  concern  about  the risk of pandemic influenza.4  Added to these concerns  is the recognition that common microbial pathogens are  becoming increasingly resistant to antimicrobial therapy.  In the face of a re-emerging threat of respiratory infections, prevention is increasingly important.  Several guidelines on control of respiratory infections  were  issued  both  before  and  after  SARS.5-10  Guidelines,  however,  are  not  always  implemented.  There  is  a  well  documented  gap  between  what  ought  to  be  done  and  what  is  being  done.  It  is  now  clear  that  programs  designed  only  to  increase  physicians’  knowledge,  such  as traditional continuing medical education courses, are  ineffective in changing physicians’ behaviour.11-13 Growing evidence indicates that interventions involving  multiple  strategies  are  more  likely  to  result  in  improved  practice  behaviour  than  single-strategy  interventions  are.14-18  Bero  et  al19  looked  at  18  systematic  reviews  covering  more  than  400  research  papers  on  improving professional performance and concluded that  multifaceted  facilitation  interventions  are  effective  in  persuading  physicians  to  incorporate  good  preventive  practices into routine care. More recent reviews20-22 indicate  that  more  research  is  needed  to  clarify  whether  multifaceted  interventions  are  better  than  single  interventions.  Interventions  tailored  to  overcome  barriers  appear to be the most effective. One  of  the  most  effective  multifaceted  strategies  is  outreach  facilitation.  Outreach  facilitation  involves  having  trained  professionals  working  directly  with  physicians in their offices and uses audit of current practice,  evidence-based  best  practices,  planning  and  consensus  building,  and  feedback  on  performance  change  as  means  to  improve  practice.23  Several  randomized  controlled trials have shown outreach facilitation to be successful in improving delivery of preventive services and  prescribing.24-28  One  trial  done  in  Ontario29  showed  an  absolute  change  of  11.5%,  or  a  relative  improvement  of  36%,  in  preventive  practices  after  an  intervention,  a  result similar to those found in comparable trials.20,30-35 In keeping with the post-SARS recommendation that  primary care and public health services work more collaboratively,36  this  research  was  a  joint  initiative  of  the  University of Ottawa’s Family Medicine Department and  the  City  of  Ottawa’s  Public  Health  Branch.  We  trained  public  health  nurses  in  outreach  facilitation  so  they  could conduct the intervention. We evaluated both process  and  outcomes.  This  paper  focuses  on  outcomes.  Our study was designed to assess whether a short-term  outreach  facilitated  intervention  could  be  effective  in  improving practices for control of respiratory infections  in family physicians’ offices.  METHODS setting Ottawa,  Ont,  is  a  bilingual  city  with  a  population  of  approximately  800 000  people  living  in  both  urban  and  rural areas. The study was conducted