Changing clinical practice: Which interventions work?

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Changing clinical practice is a complex challenge. A framework is presented for integrating the perspectives of continuing education, technology assessment, and quality assurance. The effectiveness of current interventions is reviewed. We describe what is known about practice determinants, the most important of which are physician age, clinical training, knowledge, skill, personal characteristics, practice setting, and reimbursement policies. The relative importance of these factors varies and seems to be condition-specific, an important point to be considered in the selection of practice interventions.Interventions aimed at having an impact on the practice setting (e.g., practice aids or audit programs), or on reimbursement policy (e.g., the fee allowed for a service) are more likely to bring about a change in practice than are interventions aimed at changing physician knowledge or skill. This is attributed to the greater relevance of these interventions for the individual physician, and to the opportunities provided for practicing them and for feedback. The cost and feasibility of using the various types of interventions to bring about practice change have to be carefully weighed against the expected benefit for patients. Those seeking to select strategies that will optimize the effectiveness of interventions will need to consider the relative importance of physician abilities and attitudes, practice barriers, and economic disincentives to practice change.

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