The dissemination of educational materials alone (e.g. newsletters, clinical guidelines, and audiovisual materials) is used commonly as a behavior change strategy, although this approach has been shown repeatedly to be ineffective as a stand-alone intervention 69. This strategy was one arm of an RCT conducted by Majumdar et al 13 in the form of a clinical guideline and 'toolkit' (a list of eligible patients and patient educational materials); another arm of this trial evaluated the impact of group education (discussed below). Not surprisingly, the materials only intervention failed to increase the testing and treatment of Helicobacter pylori (HP) infection or to reduce proton pump inhibitor and histamine-2 blocker prescribing.

One-to-one educational outreach (often referred to as academic detailing) has been shown to be an effective technique to change many aspects of physician behavior, particularly medication use 1415. Simon et al 16 demonstrated that one-to-one education sessions delivered by peer leaders increased guideline adherence and the use of diuretics and beta-blockers for hypertension.

Two studies evaluated the impact of one-to-one patient counseling by pharmacists. One intervention successfully decreased mortality rates in patients using drugs with a narrow therapeutic index; hospitalizations were also reduced by both brief and detailed pharmacist counseling, although the effects were not significant 17. Results from another study 18 showed that detailed pharmacist counseling on adherence to medications with follow-up telephone calls did not increase the rate of eradication of HP infection over pharmaceutical treatment without counseling, but it did increase patient satisfaction.

Group education relies on either didactic or problem-based approaches to influence behavior 7. In our review peer leader education in small practice-based groups was shown to increase testing and treatment for HP infection; however, it was unsuccessful in reducing the use of proton pump inhibitors or histamine-2 blockers 13. Simon et al 16 demonstrated that an intervention involving group academic detailing improved antihypertensive prescribing; individual academic detailing was more successful than group visits in increasing the use of diuretics and beta-blockers as recommended by clinical guidelines. There is some evidence that both group and individual detailing interventions are cost-saving 1619. Another study using group academic detailing by psychiatrists and interactive discussions to improve depression management by primary care physicians demonstrated no significant increase in antidepressant prescribing or treatment duration at 12 months post-intervention 20. A significant reduction in antibiotic prescription rates was achieved over a 3-year period by using a multifaceted intervention comprised of peer leader education sessions to practitioners, provision of mailed educational materials (based on materials from the Centers for Disease Control and Prevention) to parents of young children, and dissemination of key educational messages via radio, newspaper, television and pamphlets in hospitals, clinics, and pharmacies directed at the general public 21.

Audit and feedback interventions report physicians' past or current clinical practice, usually in relation to the practice of peers or accepted standards. Audit and feedback can achieve small to moderate improvements in physicians' practice 2223. Four studies in this review used prescriber feedback combined with educational materials to change medication use. Providing clinical recommendations to physicians with annual mailed peer-comparison feedback over a four-year period achieved small increases in the use of statins, beta-blockers, and angiotensin-converting enzyme inhibitors among patients with coronary heart disease 24. Simon et al 25 demonstrated that internet-based feedback to residents on their prescribing practices complemented by educational materials did not increase the proportion of diabetic patients receiving glycemic monitoring or change antihypertensive prescribing. However, residents were required to actively access a password-protected personalized website to be exposed to the intervention 25.

Two studies targeted physicians and patients using educational materials and feedback. The first achieved a small reduction in antibiotic prescribing for acute respiratory tract infections by delivering practice guidelines and performance feedback to physicians, combined with mailing educational materials to patient households and placing information in waiting and examination rooms 26. In the second study, a significant increase in antidepressant adherence was achieved by providing physicians with a list of non-adherent patients, guidelines, and feedback on their prescribing, along with mailing educational information to patients initiating therapy and reminder letters to non-adherent patients 27.

The common types of information technology used in clinical care include electronic medical records, computerized physician order entry, and real-time decision support (such as reminders and prompts). Computerized order entry with clinical decision support has been demonstrated to improve prescribing and reduce medication error rates 28. Smith et al 29 used a computerized provider order entry system to provide prescribing alerts regarding medicines with potential contraindications and therapeutic alternatives. They found a reduction in dispensing rates of potentially contraindicated medicines (including tricyclic-antidepressants) among the elderly (aged > 65 years). Another intervention of electronic reminders to providers successfully increased the proportion of female patients receiving osteoporosis medications or bone mineral density measurements; total calcium intake, as a measure for quality of care, also increased 30. The addition of patient reminder letters did not increase the impact of alerts alone on the target outcomes 30.

Two studies in this review combined computerized alerts and group academic detailing 3132. Interrupted time series analyses demonstrated that computer-based drug-specific and patient age-specific alerts were effective in reducing prescribing of medications that interact with warfarin 31 and the use of medications contraindicated in the elderly 32. In both studies, group education failed to achieve any additional change in medication use over the alerts alone.

Bambauer et al 33 evaluated the impact of alerting prescribers via faxed letters about patients who had gaps of more than 10 days in refilling anti-depressant prescriptions during the first six months of therapy. The faxed alerts to prescribers had no discernable effect on the proportion of non-adherent patients or the number of days without antidepressant treatment during the 12-month follow-up period.

The effectiveness of computerized reminders has also been demonstrated to improve rates of recommended laboratory drug monitoring. In two studies by Raebel et al 3435 daily computerized alerts identifying incomplete laboratory tests for a range of drugs (such as amiodarone, carbamazepine, and statins) were sent to pharmacists who telephoned patients about the missing tests. This intervention successfully increased the completion of laboratory monitoring both at the initiation of and during the course of drug therapy 3435. In contrast, neither non-intrusive computerized alerts to physicians, nor presenting information on computer screens without requiring additional actions, were ineffective in changing laboratory monitoring rates at the initiation of drug therapy 36.

A study by Feldstein et al 37 compared three interventions to increase laboratory test completion for drugs prescribed frequently in primary care. Electronic reminders to providers about missing laboratory tests, with accompanying sample letters for distribution to patients, were successful in increasing the proportion of patients completing tests; however, the impact was greater when patients were contacted directly. Two other interventions – reminding patients about incomplete tests via automated telephone voice message or telephone calls by nurses – were both more effective than patient-specific alerts to providers in increasing laboratory test completion 37.

Telephone outreach to patients by pharmacists was evaluated in three papers. In one study 3839 three monthly telephone calls by pharmacists to monitor patients taking antidepressants increased medication adherence and improved depression symptoms, and not surprisingly, increased patient feedback to pharmacists about medication use 3839. However, in the management of asthma, three outreach telephone calls about five months apart with tailored feedback to patients did not change medication or healthcare utilization 40.

Tiered formularies with different levels of patient copayment to encourage use of preferred drugs are used increasingly to enhance cost-effective use of medicines 41. Six papers in this review evaluated the impact of tiered formulary changes.

Changing from a single copayment to a three-tier structure reduced continuation of the original medications, increased switching to agents in a lower tier, discontinued use of all drugs in the affected class in some patients, and decreased plan spending while increasing enrollee spending 4243. Similar but smaller effects were observed when changing from a two-tier to a three-tier formulary 42. These changes in the pattern of medication use were seen in a number of prescription drug classes examined, including angiotensin-converting enzyme inhibitors, statins, proton pump inhibitors, and medications for attention-deficit hyperactivity disorder 4243. A change from two to three tiers decreased claims for third tier medications and net insurer costs, while patient out-of-pocket copayments increased significantly in both the first year 44 and second year 45 of follow-up. In a study by Nair et al 46 change from a two-tier to a three-tier design increased compliance of prescribers to preferred medications and increased overall medication use (primarily due to increases in use of medications in the two lower tiers).

Patient cost-sharing (either in the form of fixed, percent, or tiered copayments) is an important factor influencing medication use. Roblin et al 47 showed that large (> $10 per 30-day supply) and moderate ($7–$10) increases in cost-sharing attenuated an increasing trend of oral hypoglycemic medication use by 18.5% and 9.2% respectively over a 6-month period, while small ($1–$6) increases in copayments had no impact.

Prior authorization (PA) policies are commonly used to control drug utilization and cost 48. In a health plan that instituted a PA policy for COX-2 inhibitors, Hartung et al 49 showed a significant reduction in COX-2 inhibitor use as well as a small decrease in use of gastrointestinal protectants (e.g. proton pump inhibitors and histamine-2 blockers) at one year post-intervention. Another study demonstrated a reduction in pharmacy utilization but an increase in medical utilization (particularly hospitalization and emergency department visits) after a COX-2 inhibitor PA policy was implemented 50.

After vaginal anti-fungal products became available over-the-counter, Gurwitz et al 51 showed a significant reduction in anti-fungal prescriptions. Studies by McDonough et al 52 and Andrade et al 53 both evaluated the impact of formulary switches between agents in the same therapeutic class and found increases in the prescribing of the preferred agents (lisinopril and esterified estrogen tablets, respectively). After loratidine became available as an over-the-counter medication, Sullivan et al 54 found that prescriptions decreased for both antihistamines and the total category of allergic rhinitis medications (including inhaled corticosteroids and leukotriene receptor antagonists) with a substantial reduction in pharmacy costs for these medications. Antihistamine prescriptions were further decreased by switching antihistamines to the third formulary tier or by imposing a PA policy for these medications 54.

Two studies by Delate et al 5556 evaluated the effects of a formulary change with communication to physicians and/or patients informing them of the change. The first study evaluated the impact of notifying patients via mail of impending formulary changes 56 and showed an increase in subsequent formulary adherence. The second study used letters to notify physicians and patients of formulary changes and showed a small increase in conversion of inefficient dosage regimens to a recommended daily dosage of the same medication 55. Similarly, DeZearn et al 57 evaluated the effect of formulary change with letters to prescribers encouraging the use of generic cimetidine and found a reduction in prescriptions for the brand name product and an increase in the prescribing of generic cimetidine.

Depression is a common medical condition that is associated with significant social and functional impairment as well as high direct and indirect health care costs 65. Research suggests depression can cause greater functional disability than other chronic conditions such as diabetes, chronic lung disease, and hypertension 66.

In one study, psychiatrists reviewed patient psychosocial history and current depressive episodes over multiple sessions. The intervention, which also included books and videotapes for patient education and pharmacologic treatment where necessary, effectively increased antidepressant adherence at 12 months with modest improvements in depression symptoms among severely depressed patients 67. Katon et al 68 evaluated an individualized stepped-care depression treatment program provided by specialist nurses working collaboratively with primary care physicians for diabetic patients diagnosed with depression. The intervention increased the use of adequate antidepressant doses and drug adherence at 12 months; there were also modest improvements in depression symptoms and no change in diabetes outcomes 68. Unutzer et al 69 evaluated a quality improvement intervention targeting treatment of depression with follow-up by specialist nurses. The intervention increased the proportion of patients using antidepressants and antidepressant use according to guideline-recommended doses among patients at high risk for relapse. In the same study, an intervention with a focus on quality of psychotherapy rather than medication use was less successful than the intervention targeting improved medication therapy 69.

Ray et al 70 examined the impact of transitioning patients from traditional Medicare and MCOs to specialty behavioral health organizations ('carve-out' programs). They found a significant reduction in the proportion of patients who continued antipsychotic therapy; this negative effect was greatest in high-risk patients.

Lozano et al 71 evaluated the impact of two interventions: physician peer leader education within practice groups and peer leader education coupled with nurse care planning, telephone monitoring and follow-up of medication use, asthma symptoms and support for self-management. Both interventions effectively reduced asthma symptoms and decreased the use of oral steroids; the planned care intervention (multifaceted) had a greater effect on these target outcomes than the group education intervention 71. However, at the practice-level, the two intervention approaches did not differ in changes in the proportion of patients using controller medications or oral steroids, or in frequency of medical visits 72.

Published guidelines recommend testing for HP in patients receiving long-term acid suppression therapy for acid-related disorders, and antibiotic treatment for those with HP-positive peptic ulcer disease 7374. A test and treat intervention for HP infection in patients receiving long-term acid-reducing therapy successfully improved gastrointestinal symptoms and reduced the use of acid-reducing medications and associated costs at 12 months 75. Ofman et al 76 evaluated another test-and-treat program for HP infection provided collaboratively by physicians, pharmacists and nurses. This multifaceted intervention involved local development and implementation of test-and-treat guidelines, individual and group academic detailing, patient education by pharmacists, and HP testing and medication monitoring by nurses. The intervention successfully increased compliance with HP testing and the proportion of patients prescribed appropriate anti-HP therapy at six months with no significant change in total costs of related health services 76.