Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA; CDC Foundation, Atlanta, GA, USA.
Lancet Glob Health. 2018 Nov;6(11):e1163-e1175. doi: 10.1016/S2214-109X(18)30398-X. Epub 2018 Oct 8.
Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs.
For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154.
We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR -2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, -4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3-15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0-18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0-37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2-125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence.
The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions.
Bill & Melinda Gates Foundation, CDC Foundation.
医疗服务提供者表现欠佳是中低收入国家（LMICs）提供高质量医疗服务的主要挑战。医疗服务提供者绩效审查（HCPPR）是对改善 LMICs 医疗服务提供者绩效的策略进行的全面系统评价。
我们对从 20 世纪 60 年代到 2016 年的 52 个电子数据库进行了发表研究和 58 个文献目录的搜索，以寻找未发表的研究。合格的研究设计包括对照试验和间断时间序列。我们只包括了策略与对照组的比较。我们报告了改善医疗服务提供者实践结果的效果大小，以百分比（例如，正确治疗的患者百分比）或连续措施（例如，每位患者开的药物数量）表示。效应大小计算为绝对百分点变化。每个比较的汇总测量值是所有主要结局的中位数效应大小（MES）。策略有效性用 MES 的加权中位数来描述。本研究在 PROSPERO 注册，编号 CRD42016046154。
我们筛选了 216477 条引文，并从 337 项研究中选择了 670 份报告，涉及 118 项策略。大多数策略都有多个干预组成部分。对于专业医疗保健提供者（通常是基于机构的卫生工作者），仅实施基于技术的策略（中位数 MES 为 1.0 个百分点，IQR -2.8 至 9.9）或仅向医疗保健提供者提供印刷信息的效果几乎为零（1.4 个百分点，-4.8 至 6.2）。对于百分比结果，单独培训或监督通常具有中等效果（10.3-15.9 个百分点），而培训和监督相结合的效果则略大于单独使用任何一种策略的效果（18.0-18.8 个百分点）。单独的小组解决问题显示出百分比结果的大幅改善（28.0-37.5 个百分点），但当策略定义扩大到包括单独的小组解决问题或其他策略组成部分时，中等效果更为常见（12.1 个百分点）。一些多方面的策略具有较大的效果，但多方面的策略并不总是比简单的策略更有效。对于非专业医疗保健提供者（通常是社区卫生工作者），单独培训的效果很小（2.4 个百分点）。效果较大的策略包括社区支持加医疗保健提供者培训（8.2-125.0 个百分点）。背景和方法学的异质性使得比较变得困难，而且大多数策略的证据质量都较低。
改善医疗服务提供者实践的策略的影响差异很大，尽管有些方法比其他方法更一致有效。HCPPR 的广泛程度使其结果对决策者具有价值，有助于决策者选择改善 LMIC 医疗服务提供者实践的策略。这些结果还强调了研究人员需要使用更好的方法来研究干预措施的有效性。
比尔和梅琳达·盖茨基金会，疾病预防控制中心基金会。
