title: Practice-level quality improvement interventions in primary care: a review of systematic reviews.
abstract: OBJECTIVE
  To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews.
  
  
  BACKGROUND
  Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care--the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting.
  
  
  METHODS
  
  
  
  METHODS
  A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions.
  
  
  METHODS
  Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions.
  
  
  METHODS
  A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions.
  
  
  RESULTS
  Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions.
  
  
  CONCLUSIONS
  Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.
authors.affiliation: 1Primary Care Clinical Sciences,School of Health and Population Sciences,College of Medical and Dental Sciences,University of Birmingham,Edgbaston,Birmingham,UK.
authors.forename: Ryan
authors.initials: R
authors.lastname: Irwin
authors.affiliation: 2Elaine Gurr Professor of General Practice,Department of General Practice and Rural Health,University of Otago,Dunedin,New Zealand.
authors.forename: Tim
authors.initials: T
authors.lastname: Stokes
authors.affiliation: 3Professor of Public Health and Primary Care,Primary Care Clinical Sciences,School of Health and Population Sciences,College of Medical and Dental Sciences,University of Birmingham,Edgbaston,Birmingham,UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Marshall
mesh_terms: D058006:General Practice / Q000592:standards; D006801:Humans; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement; D000078202:Systematic Reviews as Topic
keywords: primary care; quality improvement; systematic review